The Health and Wellbeing of Children and Young People in Powys

Transcription

1 The Health and Wellbeing of Children and Young People in Powys Director of Public Health Annual Report 2013/14 Powys teaching Health Board

2 Contents Chapter Page Foreword Recommendations Acknowledgements 1 Introduction 2 The Powys Context 3 Maternal and Infant Health 4 The Early Years 5 School Years 6 Young People (16 to 24 years) 7 Protecting Children from Harm 9 Listening to Children References Appendix 1 Appendix 2 NICE Public Health Guidance Implementation in Powys Indicators from Health of Children and Young People in Wales, Public Health Wales Observatory Page 2 of 106

3 Foreword Dear Reader Welcome to the 2013/14 Annual Public Health Report for Powys. Considering recent reports, the 2011/12 report focused on the importance of prevention in maximising health and wellbeing. In 2012/13, the report focused on the key determinants of health and wellbeing and the importance of partnership working. This 2013/14 report focuses on the health and wellbeing of children and young people in Powys. The report adopts a life course approach for these early years, while recognising that some of the themes and challenges - for example parenting and lifestyle choices - are cross cutting. While no chapter of the report is a comprehensive review, each chapter draws together the most recent, routinely available intelligence (particularly from Public Health Wales) in describing health and wellbeing issues for that age-group. The report also summarises some of the programmes and actions in place in Powys to improve health and wellbeing. Key messages to emerge include that: Although low numbers are involved, stillbirth, perinatal, neonatal and infant mortality rates in Powys are relatively stable and the most recent rates are not significantly different from Wales. The picture is the same for the proportion of Powys babies born with a low birth weight (less than 2,500g). There is some, albeit limited, population-level evidence that babies born in the more socioeconomically deprived areas of Powys are more likely to be of low birth weight Maternal smoking remains a significant threat to the health and wellbeing of mothers and their babies in Powys; further work is needed to address this issue. On the other hand, breastfeeding is a continuing success story in Powys The latest intelligence from the Wales Child Measurement Programme provides evidence that combined rates of overweight and obesity amongst reception year children are improving, both nationally and in Powys. However, there is some evidence that obesity rates are relatively more static in this age group. Rates in Powys are not significantly different from Wales Rates of smoking and alcohol misuse amongst young people in Powys tend not to be significantly different from rates across Wales; rates remain too high and are likely to be an underestimate of risk-taking behaviour In general, there have been significant improvements in the uptake of routine childhood vaccinations in Powys over the last ten years or so. However, further work is required to deliver and secure performance at national target level, for some elements of the programme. There is some evidence that the relationship between socioeconomic status and vaccination uptake is not entirely as expected in Powys As measured by dental decay in five and twelve year olds, oral health is improving in Powys Rates of some sexually transmitted infections are relatively low in Powys, although may be underestimated from current data sources Population-level child protection registration rates are relatively low in Powys compared to the other Welsh Local Authorities; the trend in population registration

4 rates over recent years in Powys is different to the picture across Wales. This may be due to improvements in care planning and effective interventions with families. While the pattern is not completely consistent, considering the measures of health status presented in this report, there are some similarities between Powys and other more rural areas in Wales. There may be further opportunities for joint learning Effective partnership working underpins the local effort to improve the health and wellbeing of young people in Powys. Within this, there are opportunities for the voices of young people, their families and carers to be heard even more loudly in planning and evaluating local services I have made eight recommendations for further action. As reported at the time, I will review progress with the recommendations of my 2012/13 report in 2014/15. I am extremely grateful to the very many individuals who contributed ideas, information and text for this report. I hope you find it an enjoyable and useful read. As ever, both I and the Powys Public Health Team welcome all feedback and suggestions. Dr Catherine Woodward Director of Public Health, Powys teaching Health Board November 2014 Page 4 of 106

5 Recommendations 1. Senior lead officers from Powys teaching Health Board should explore whether there are any opportunities to further develop and tailor support for pregnant smokers, based on lessons learned from the local breast feeding programme 2. Powys teaching Health Board should further explore the relationship between local vaccination rates and socioeconomic status, with support from Public Health Wales. Immunisation plans may need to be updated in the light of this review 3. The Powys Healthy Weight Steering Group should review the scope and impact of its actions in preschool settings. This work may need to take due account of the outcome of the current health improvement review by Public Health Wales 4. The Powys Children and Young People s Partnership should receive a comprehensive report on the Powys Healthy Preschools and Schools schemes on an annual basis, encompassing outcome measures 5. Powys teaching Health Board should further explore and address local inequities in the uptake of NHS dental services amongst children and young people 6. The Powys teaching Health Board Public Health Team should lead a needs assessment of local sexual health services during 2015/16. This should encompass services provided and commissioned by the Health Board, to ensure effectiveness and value for money 7. As part of the wider engagement work being led by the Powys Children and Young People s Partnership, Powys teaching Health Board should ensure that its refreshed engagement strategy fully encompasses children and young people 8. Leading on from this, Powys teaching Health Board should receive an annual report on all its engagement activities with children and young people in Powys Page 5 of 106

6 Acknowledgements Many people contributed to the writing, production and oversight of this report. In particular, I would like to thank Dr Sumina Azam, Nicola Gordon and Marie Grannell for coordinating the production of this report. Editorial Group Dr Sumina Azam, Consultant in Public Health, Powys Public Health Team Anna Childs, Advanced Public Health Intelligence Analyst, Public Health Observatory, Public Health Wales Dawn Davies, former Lead Midwife South Powys, Powys teaching Health Board Nicola Gordon, Principal Public Health Practitioner, Powys Public Health Team Marie Grannell, Senior Health Promotion Practitioner, Powys Public Health Team Helen James, Head of Childrens Public Health Nursing and Community Paediatrics, Powys teaching Health Board Gregory Jones, Children and Young People s Partnership, Powys County Council Cate Langley, Head of Midwifery and Sexual Health, Powys teaching Health Board Ruth Marks-Twelvetrees, former Head of Childrens Public Health Nursing and Community Paediatrics, Powys teaching Health Board Dr Catherine Woodward (Chair), Director of Public Health, Powys teaching Health Board Contributors Powys Public Health Team Sophia Bird, Principal Public Health Specialist Mary Evans, Powys Healthy Schools Co-ordinator Kate Heneghan, Senior Health Promotion Practitioner Jayne Ingram-Jones, Business Support Manager Rhiain Murphy, Public Health Dietician Team Lead Abigail Peat, Public Health Dietician Powys teaching Health Board Jacqui Bennett, Community Dental Service Sharon Fernandez, Flying Start Health Visitor Pauline Gallucio, Head of Safeguarding Jayne Garfield, Specialist Nurse Looked After Children Shelly Jones, Lead Midwife South Powys / Public Health Marie Lewis, Practice Development Midwife Clare Lines, Head of Clinical Strategy Tess Lister, Lead Health Visitor Mary Morton, Specialist Nurse, Looked After Children Warren Tolley, Clinical Dental Director Bernette Venables, School Nurse Team Leader

7 Powys County Council Chris Cooper, Senior Manager for Schools Data Services Shelley Davies, Senior Partnership Manager, Children and Young People s Partnership Nikki Davies-Wheeler, Trading Standards Officer Pauline Higham, Head of Children s Services Geraint Morgan, Research Officer Sue Morgan, Interim Safeguarding Lead for Children (author of Chapter 7 Introduction) Ian Roberts, Head of School Services Public Health Wales Dr Hugh Bennett, Consultant in Dental Public Health, Public Health Wales Andrew Dring, Public Health Information Officer Arthur Duncan-Jones, Public Health Intelligence Analyst Dr Sharon Hillier, Deputy Director, Screening Division, Public Health Wales Maria Morgan, Senior Lecturer in Dental Public Health Bethan Patterson, Senior Public Health Intelligence Analyst Rhys Powell, Public Health Intelligence Analyst Tracy Price, Advanced Public Health Intelligence Analyst Eleanor Thomas, Public Health Intelligence Analyst Mary Wilson, Specialty Trainee, Dental Public Health, Public Health Wales Powys Carers Dux, Team Leader, Powys Young Carers Gyles Palmer, Director, Powys Carers Finally, I would like to thank staff and pupils at Penmaes School, Brecon, for the art work used in this report. Page 7 of 106

8 1 Introduction Important foundations for good health are created during pregnancy and the early years. The experiences and circumstances individuals are exposed to during this period influence future life chances. Action to reduce health inequalities and improve population health and wellbeing must start before birth and continue across the life course (Welsh Government 2011). Figure 1: Cumulative impact of actions across the life course on health and wellbeing Source: The Marmot Review, 2010 There are a range of factors that impact on the health and wellbeing of children, including parenting, the home environment, education, access to services, the wider community, family structure and relationships, income and poverty (figure 2). Figure 2: Factors that influence a child s health in the early years Source: Welsh Government Poverty in the early years has a long lasting and deep impact. For example, pregnant women living in poverty are more likely to be in poor health, gain less weight, be more likely to smoke and have babies that are born early, weigh less and are at increased risk of infant mortality. The risk of sudden death in infancy is approximately nine times higher in a child in Page 8 of 106

9 the lowest socio economic class. Children living in poverty are more likely to be admitted to hospital and suffer from mental health problems, including deliberate self harm (Spenser N in Department of Health, 2013). Fuel poverty is also linked with a range of adverse outcomes, including poor weight gain in infants and increased risk of hospital admissions amongst children. Cold homes in particular are linked to decreased educational attainment and reduced emotional wellbeing and resilience in children and young people. Poor housing is associated with increased school absence and respiratory disease (Department of Health, 2013). Our Healthy Future (Welsh Government, 2010) outlines a need to gain commitment from a range of policy areas and partners including housing, transport, culture and sport, education and skills, economic development and rural affairs across the statutory, private and voluntary sectors in order to reduce health inequalities. The Determinants of Health and Wellbeing There are a number of determinants impacting on an individual s health (figure 3). These include age and sex, as well as lifestyle factors such as smoking and physical activity levels. Other influences on health and wellbeing are social and economic factors, living and working conditions and socioeconomic, cultural and environmental conditions. Figure 3: The Determinants of Health. Source: Dahlgren and Whitehead (1991) Promoting and protecting the health and wellbeing of children and young people can help to prevent ill health in adults. This can be achieved through: Professionals, such as maternity services and social services, providing support to parents and families Programmes targeting those most in need, such as looked after children or those living in more deprived areas Working in specific settings such as nurseries and schools Page 9 of 106

10 Helping children to become resilient and able to cope with life challenges through specific programmes such as parenting programmes and the Healthy Schools Scheme Ensuring that local polices, strategies and action plans address the broader determinants of health and wellbeing such as housing, physical environment and accessibility of services Page 10 of 106

11 2 The Powys Context This chapter focuses on intelligence related to children and young people. All Age data for Powys can be found in Local Area Summary Statistics at Welsh Government Statistics and Research webpage: Much of the data and intelligence in this report is sourced from The Health of Children and Young People in Wales (Public Health Wales Observatory, 2013), which provides health related statistics from birth until 24 years of age for a range of topics: Population and births Socio-economic and environmental conditions Families and education Health related behaviours Immunisations and screening Health and use of health services Deaths in children and young people Powys Demography Powys teaching Health Board has a population of 132,700 (2013 MYE, Office for National Statistics). 26.2% of the Powys population are aged under 24 years compared with 30.1% in Wales and the 30.4% in the UK. However, as no confidence intervals are presented for this data, is not possible to determine if this difference is statistically significant. In 2002, 27.6% of the Powys population was aged under 24 years, compared with 31.0% in Wales. Figure 4: % of population aged 0 to 24, 2013 % of population aged 0-24, UK nations and health boards, 2013 Produced by Public Health Wales Observatory, using MYE (ONS) 0-4 years 5-11 years years years Total United Kingdom Scotland Northern Ireland England Wales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Page 11 of 106

12 Source: Public Health Wales Observatory, using MYE (ONS) Figure 5 compares the population structure of Powys with that of Wales. This shows that in Powys, a larger proportion of males and females are aged 45 years and over compared with Wales. Figure 5: Proportion of population by age and sex, Powys and Wales 2013 Produced by Public Health Wales Observatory, using 2013 mid year population estimates, ONS Wales Males Powys Males Wales Females Powys Females Proportion (%) of population Deprivation and Child Poverty in Powys The Welsh Index of Multiple Deprivation 2011 Child Index is a measure of relative deprivation for small areas in Wales for children. It comprises seven domains: income, health, education, geographical access to services, community safety, physical environment and housing. Mapping of child deprivation in Powys (figure 6) shows that the most deprived Lower Super Output Area (geographical area containing a population of 1500 on average) is Brecon St John. More deprived Lower Super Output Areas also include Ystradgynlais and parts of Llandrindod, Welshpool and Newtown. Page 12 of 106

13 Figure 6: Child deprivation in Powys In the most recent available data from 2011 (figure 7), there were 3,375 children (13%) aged under 20 years living in poverty in Powys, which is defined as children in families whose household income is less than 60% of the median UK income in 2010, or children in families who are in receipt of income support or Income-Based Jobseekers Allowance. This proportion is significantly lower than the position across Wales (21.9%). This proportion has decreased across Wales and Powys since 2009 (Wales 22.7%, Powys 13.8%) and 2010 (Wales 22.2%, Powys 13.4%), although it is not possible to determine from data presented in the Health of Children and Young People in Wales report (Public Health Wales Observatory 2013) if this difference is statistically significant. Page 13 of 106

14 Figure 7: % of children living in poverty, persons aged under 20, 2011 % of children living in poverty, persons aged under 20, 2011 Produced by Public Health Wales Observatory, using DWP Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Wales= 21.9% Source: Produced by Public Health Wales Observatory, using DWP In Powys, it is estimated that 1,100 children lived in workless households in 2012, which was 6.1% of all households in Powys. However, as this data was based on less than 40 responses to the Annual Population Survey, it is categorised as being of limited quality (Stats Wales). According to the most recent available data (2013/14), 10.8% of pupils in primary, secondary and special schools in Powys were eligible for free school meals, significantly lower than the position across Wales (19.1%) (Powys County Council). Educational attainment outcomes were worse in those who were eligible for free school meals. Across Wales in 2012/13, 88% of pupils not eligible for free school meals achieved at least the expected level (Level 4) in teacher assessments in Core Subject Indicator (English or Welsh first language, mathematics and science in combination) at Key stage 2 (7 years age), compared with 70% of pupils who were eligible (Welsh Government 2014). In Powys this figure was 88% for those not eligible for free school meals, compared with 74% who were eligible (figure 8). Page 14 of 106

15 Figure 8: N.b Wales Not eligible for FSM is represented in Figure 8 by red data points Source: Powys Children and Young People s Partnership The Key Role of Partnership Partnership working is fundamental to tackling the root causes of poor health and health inequalities. The development of a single integrated plan (One Powys Plan) has further brought together strategic partnerships and organisations within Powys. There are established examples of good practice within these strategic partnerships, which will be explored further later in the report. Powys Children and Young People s Partnership Powys Children and Young People s Partnership (CYPP) has overarching strategic leadership responsibility for the planning, development and commissioning of services to meet the needs and improve outcomes for children and young people. The partnership has representation from public, private, voluntary and community sectors and its success is dependent on co-operation between the partner agencies in order to reach collective decisions and drive progress. The Powys Children and Young People s Partnership produces a single strategic three year overarching plan for all services affecting children and young people, which is reviewed on Page 15 of 106

16 an annual basis. The partnership has a range of subgroups, which lead specific areas, including: Modernising learning Family support and childcare Active and healthy lifestyles Mental health and wellbeing Promoting social inclusion Disability Infrastructure Safeguarding School improvement Children and Young People s Partnership: Vision For all children and young people living in Powys to reach their full potential by having access to the services they need and that those services value and respect them (and their parents and their carers) and promote their health, wellbeing, learning and development. Source: In overview, the partnership has developed a common framework, mapping service provision across four tiers: 1. Universal services: available to meet a range and level of needs. Most children and young people will require these services 2. Targeted services: provide extra help for those with additional needs, usually in addition to continued access to universal services 3. Referred services: service providers will have particular skills to meet higher levels of additional needs 4. Specialist services: for children and young people with complex needs Page 16 of 106

17 Case Study - Powys Young Carers Powys Young Carers service works in partnership with the Children and Young People s partnership to offer one to one and group support and a range of activities and events to young carers in Powys. One to one support is based around information, advice, guidance and advocacy and is aimed at enabling young carers to overcome difficult and challenging realities and improving life chances. The programme of respite activities offered aims to build resilience within young carers and generate positive life experiences. The young carers team offers emotional support and listening time to young carers but also recognises the specialist support of colleagues and partner agencies and thus acts in a signposting role where appropriate. A focus remains on providing support to unpaid family carers. This group includes a higher than normal number of young carers who are not in employment, education or training, with many experiencing higher levels of poverty and mental ill-health and higher risk of substance misuse. Source: Powys Carers Page 17 of 106

18 Implementation of National Institute of Health and Social Care Excellence (NICE) Guidance in Powys NICE has published numerous Public Health guidance for implementation at local level. Appendix 1 provides an overview of NICE guidance relevant to children and young people and its implementation in Powys. Overview of Health in Children and Young People Appendix 2 presents a series of charts from the Health of Children and Young People In Wales (Public Health Wales Observatory, 2013), which provide detailed information on the health status of children in Powys. This intelligence is in addition to that presented elsewhere in this report. Key points to note include: In 2011, 5.7% (3,351) of all households in Powys had a lone parent with dependent children, compared with 7.5% of households in Wales In 2011, 4.1% (2,410) of all households in Powys had dependent children, where one person had a long term condition or disability. Across Wales, the position was 5.2% In 2011, there were 1,066 (3%) children and young people aged 24 years and under who provided unpaid care in Powys, compared with 3.2% in Wales In 2011/12 in Powys, there were 141 referrals for drug misuse (54 per 100,000 population) and 125 referrals for alcohol misuse (41 per 100,000 population) in children and young people aged 24 years and younger. In Wales, the referral rate was 68 per 100,000 for drug misuse and 41 per 100,000 for alcohol misuse. The difference in referrals for drug misuse between Powys and Wales may not be statistically significant In 2011, 928 males (5.1%) and 619 females (3.7%) aged under 25 years had a long term health problem or disability compared with 5.7% of males and 4.3% of females across Wales In 2012, there were 2,580 emergency admissions (79.0 per 1,000) amongst children and young people aged under 25 years in Powys, significantly lower than the rate across Wales (102.3 per 1,000) Over a ten year period between 2002 and 2011, there were on average 3 deaths each year in Powys due to transport accidents. The rate in Powys (7 per 100,000 population) was not significantly different to the rate in Wales (5.1 per 100,000 population) Page 18 of 106

19 3 Maternal and Infant Health Summary This chapter describes the central role of maternal and infant health on the health, wellbeing and life chances of children and young people. A summary is provided on the main modifiable risk factors in pregnancy. Powys key health outcome data such as stillbirths, perinatal mortality, neonatal mortality, infant mortality and low birth rate are presented. Actions being taken in Powys to improve maternal and infant health, including monitoring intrauterine growth, antenatal and newborn screening, advice on smoking cessation, healthy weight, vaccination in pregnancy, mental health, and promotion of breastfeeding are summarised. Where available, data on each of these topics is presented, providing a picture of the current position in Powys. Introduction As discussed in Chapter 1, the foundations for health and wellbeing are laid in pregnancy. Children need a healthy start, parental nurturing and the right social environment in which to grow. Modifiable Risk Factors in Pregnancy Some behaviours or circumstances during pregnancy are associated with worse outcomes for the pregnancy or the child. Modifiable risk factors are those that can be prevented. Examples of modifiable risk factors include: Smoking: Harmful effects include low birth weight, preterm birth, increased risk of miscarriage, stillbirth, neonatal death and sudden infant death syndrome Alcohol: Heavy alcohol consumption during pregnancy causes foetal alcohol syndrome Obesity: Obesity in pregnancy is associated with an increased risk of a number of serious adverse outcomes including miscarriage, gestational diabetes, preeclampsia, stillbirth and neonatal death. There is also a higher caesarean section rate and lower breastfeeding rate in this group of women compared to women with a healthy Body Mass Index (Centre for Maternal and Child Enquiries, 2010) Diet: Under nutrition in pregnant women is linked with the development of heart disease in children in later life Illicit drug use: In pregnancy, this is associated with developmental problems in children Source: Department of Health (2013) Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays. London: UK Government. The evidence base relating to interventions for modifiable risk factors is summarised in Table 1. The strength of evidence for interventions is variable. For example, there is robust Page 19 of 106

20 evidence for the positive benefit of folate supplementation at conception and during early pregnancy; there is more limited evidence on the long term effects on children of interventions to reduce gestational weight gain. Table 1: Interventions for modifiable risk factors Intervention Smoking cessation Interventions for reducing alcohol consumption in pregnant women Interventions to reduce gestational weight gain Evidence Behavioural interventions can increase smoking cessation rates during pregnancy and reduce low birth weight and preterm birth. However, the evidence for the effectiveness of nicotine replacement therapy in pregnancy has been equivocal with better quality studies showing little or no effect on foetal outcomes. There is a need for interventions that can penetrate the so-called hard-to-reach groups where smoking prevalence remains high and standard interventions may not work as well. Although somewhat controversial, the case for using financial and other incentives to promote smoking cessation in pregnancy has been proposed. Using the technology favoured by teenage smokers, such as mobile phones and social media, may be a user-friendly way to promote cessation, as well as using social marketing. A Cochrane review in 2009 found limited evidence to support the effectiveness of interventions for reducing alcohol consumption in pregnant women. It remains unclear which type of intervention to recommend. Further trials are needed. There have been no trials to evaluate the effectiveness or safety of trying to reduce weight in obese pregnant women. Interventions in pregnancy to manage weight gain can result in reduced weight gain during pregnancy, but may not affect the risk of macrosomia in the baby. Evidence of the effects of interventions on long-term child outcomes is currently poor. Improving nutrition maternal Folate supplementation given around the time of conception and continued through early pregnancy has been shown to reduce the risk of birth defects such as spina bifida. It is recommended that women take 400 micrograms of folic acid each day during this time. The Scientific Advisory Committee on Nutrition is also considering the role of iodine, having looked at fortification of flour with folic acid. Vitamin D supplementation in pregnancy is officially recommended: interim advice is that pregnant and breastfeeding women should take a daily supplement Page 20 of 106

21 containing 10 micrograms of vitamin D. However, the evidence of effects on bone health remains equivocal and little is known about the effects on other outcomes related to pregnancy. More research is needed on the effects of vitamin D supplementation in pregnancy. An independent advisory committee is reviewing current recommendations on vitamin D and will report in Managing the use of illicit drugs Perinatal mental illness and psychosocial stress Promoting breastfeeding Multifaceted interventions Guidance on the best management of women who continue to use illicit drugs during pregnancy is provided by the National Institute for Health and Care Excellence (NICE). A systematic review of psychosocial interventions for pregnant women in outpatient illicit drug treatment programmes found weak evidence of effect on retention in treatment but more evidence is required. Since stress may be a manifestation of an underlying psychiatric disorder such as depression or anxiety, pregnant women complaining of symptoms of stress and women with other symptoms of psychiatric illness should be evaluated in accordance with the NICE guideline on antenatal and postnatal mental health. For stress which is not related to an underlying disorder then relaxation, exercise or counselling may be beneficial but there has been no clear evidence on how best to intervene. This is another area where intervention evaluation is needed. Breastfeeding has been shown to have important effects on child health, including neurodevelopment. The World Health Organization recommends that infants should be exclusively breastfed until six months of age. Yet breastfeeding initiation is low in more disadvantaged groups of women. Interventions to promote initiation of breastfeeding are effective as are interventions to prolong the duration of time for which a woman breastfeeds. Work in the USA identified the importance of starting an early childhood programme during pregnancy in order to give a child the best start in life. The Nurse-Family Partnership programme specifically aims to improve pregnancy outcomes by helping pregnant women to engage with prenatal care, improve their diets, and reduce smoking, alcohol and illicit drug use. Forty years on, the programme s effects have been evaluated in three randomised controlled trials and substantial benefits across multiple domains for both mothers and children have been demonstrated. A more recent innovation in the USA has been group prenatal care where women receive their care in groups rather than Page 21 of 106

22 individually. Evidence suggests that women receiving group care have equivalent or improved pregnancy outcomes compared with traditional prenatal care. Some sites in the UK are implementing group antenatal care and evidence is expected soon. These models may also be effective in ensuring continuity of care and developing peer support during pregnancy. Pre-conception care Pre-conception care is very important for women with established medical or psychiatric disorders. For women who are otherwise well it provides an opportunity to encourage healthy choices and establish folate supplementation. Source: Department of Health (2013) Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pay. London: UK Government. Key Outcomes Stillbirth and Perinatal Mortality The UK definition of stillbirth is foetal death after 24 weeks gestation. Perinatal death is defined as stillbirth and death in the first week of life. For a proportion of stillbirths, no cause is identified. Where identified, antepartum or intrapartum haemorrhage, mechanical problems and major congenital anomalies were leading causes of stillbirth (All Wales Perinatal Survey 2013). Across Wales, there has been a decline in stillbirths in recent years, as shown in figure 9. Page 22 of 106

23 Figure 9: Stillbirths (excluding late terminations): Three year rolling average rates in Wales ( to ) Source: All Wales Perinatal Survey 2013, using data from NCCHD and AWPS/MBRRACE- UK Perinatal mortality rates across Wales have also decreased between and (figure 10). Figure 10: Perinatal deaths (excluding late terminations): Three year average rates ( to ) Source: All Wales Perinatal Survey Page 23 of 106

24 In 2013, in 32% of perinatal deaths, the cause of death was unknown. Where known the leading causes of perinatal death were intrapartum, neonatal, infection, and congenital anomalies. A key risk factor for stillbirth and perinatal mortality is deprivation. In Wales, stillbirth and perinatal mortality rates are persistently higher in more deprived areas. Figure 11 compares stillbirth rates in the most and least deprived fifth of the population in Wales (as defined by the Welsh Index of Multiple Deprivation 2008) and shows a narrowing of the gap between highest and lowest quintiles since Figure 11: Stillbirth rates (excluding late terminations) in Wales for the most and least deprived quintiles: five year rolling rates Source: All Wales Perinatal Survey Considering the local position, relatively low numbers of deaths are involved; this affects statistical interpretation. In Powys, the stillbirth rate (excluding terminations) was 5.8 per 1,000 births in , compared with 5 in No confidence intervals for trend data are included in the All Wales Perinatal Survey 2013 to determine if this difference is statistically significant. The stillbirth rate in Powys for (5.8 per 1,000 births) was not significantly different compared with Wales average (5.0 per 1,000 births) (figure 12). There has been little difference in perinatal mortality rates in Powys between (7.6 per 1,000 births) and (7.5 per 1,000 births) (All Wales Perinatal Survey 2013). Compared with Wales (7.1 per 1,000 births), there was no significant difference in rates in Powys (7.6 per 1,000 births) for (figure 12). Page 24 of 106

25 Figure 12: Stillbirthand perinatal mortality rates per 1,000 births, Wales health boards and local authorities, Produced by Public Health Wales Observatory, using ADBE, PHMF & ADDE (ONS) Stillbirths Perinatal mortality Wales = 5.0 Wales = 7.1 Betsi Cadwaladr UHB Powys thb Hywel Dda UHB Abertawe Bro Morgannwg UHB Cardiff & Vale UHB Cwm Taf UHB Aneurin Bevan UHB Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Neonatal and Infant Mortality Neonatal mortality is defined as deaths in babies aged less than 28 days and is an indicator of the quality of care received during pregnancy and delivery. In high income countries, such as the UK, the main causes of neonatal death are complications as a result of preterm birth, congenital anomalies and infection. Locally, again, low numbers of deaths are involved. In Powys, there has been little change in neonatal mortality rates between (2.9 per 1,000 births) and (3 per 1,000 births) (All Wales Perinatal Survey 2013). The neonatal mortality rate in Powys for (2.6 per 1000 live births) is not significantly different to the rate for Wales (3.0 per live births) (figure 13). Page 25 of 106

26 Infant mortality measures the rate of deaths in children aged less than one year and provides a good indication of the overall health of children in a country or region and is strongly influenced by the health of mothers before, during and after pregnancy. The greatest effect of deprivation in infant mortality is during the post neonatal period (deaths from 28 days to 1 year of age). The infant mortality rate for Powys for (4.0 per live 1,000 births) is not statistically different to that of Wales (4.4 per 1,000 live births). In 2002, the infant mortality rate was 4.8 per 1,000 live births across Wales, compared with 3.7 per 1,000 live births in 2011; however no confidence intervals are published in the All Wales Perinatal Survey 2013 to determine if this difference is statistically significant. No infant mortality trend data has been published in the All Wales Perinatal Survey 2013 for Powys. Figure 13: Neonatal and infant mortality rates per 1,000 live births, Wales health boards and local authorities, Produced by Public Health Wales Observatory, using ADDE, PHMF & ADBE (ONS) Neonatal mortality rate Infant mortality rate Wales = 3.0 Wales = 4.4 Betsi Cadwaladr UHB Powys thb Hywel Dda UHB Abertawe Bro Morgannwg UHB Cardiff & Vale UHB Cwm Taf UHB Aneurin Bevan UHB Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend The Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Page 26 of 106

27 Preterm births The World Health Organization defines pre term births (prematurity) as babies born before 37 weeks from the first day of the last menstrual period. Prematurity is associated with greater health risks for the baby including increased risk of perinatal death, respiratory distress syndrome, infections and brain haemorrhage (NICE 2013). Increased prematurity is associated with greater risk of neurodevelopmental impairment, with 45% of babies born at weeks experiencing impairment compared with 20% born at 26 weeks gestation (Moore T et al, 2012). In 2011, there were 87 babies born preterm (under 37 weeks gestation at birth) in Powys, 7.2% of the total number of live births. This was not significantly different to the rate across Wales (7.1%) (Public Health Wales Observatory 2013). Low Birth Weight Low birth weight is defined as a birth weight of less than 2,500g. The condition is associated with a range short, medium and long-term health risks, including diabetes and heart disease (Barker 1995). Very low birth weight babies (less than 1,500g at birth) are most at risk, although there is an interplay between problems due to prematurity for some babies. Other problems include chronic lung disease (Lemons et al 2001), hearing impairment (Jiang et al 2001) and learning difficulties (De Rodrigues 2006). The proportion of babies in Powys born with a low birth weight has not changed significantly between 2004 and 2013 (figure 14). There is no significant difference in rates between Powys and Wales; in 2013, 4.8% of babies in Powys had a low birth weight which is not statistically significantly different from Wales (5.4%). Page 27 of 106

28 Figure 14: Percentage of singleton live births with a low birth weight (less than 2500g), Powys thb and Wales, Produced by Public Health Wales Observatory, using NCCHD (NWIS) Powys THB Wales 95% confidence interval 12 Percentage (%) of singleton live births Source: Produced by Public Health Wales Observatory, using NCCHD (NWIS) Figure 15 highlights the variation in low birth weight babies born by Middle Super Output Area in Powys over a 10 year period (2003 to 2012). The numbers in brackets indicate the number of Middle Super Output Areas that fall into each of the five low birth weight ranges. Llandrindod and Newtown have the highest proportion of low birth weight (between 6.2% and 7.0%), although the map does not show if these areas are significantly different to rates for Powys. Page 28 of 106

29 Figure 15: Low birth weight by Middle Super Output Area in Powys, Improving Maternal and Infant Health in Powys Midwifery Services in Powys Pregnancy offers an opportunity for health professionals to support the transition to parenthood. Midwives are often the first point of contact for pregnant women and their families and are able to assess the needs of pregnant women, providing information and referral to support services. Powys has a midwifery led maternity service, offering some women the opportunity to give birth either at home or in a community hospital birthing centre. Women requiring more specialist care are referred for consultant care outside Powys at a neighbouring District General Hospital. Powys midwifery care is provided on a one to one basis, with a focus on providing continuity of care and establishing a trusting relationship. This approach has a proven positive impact on the maternal-infant attachment process and the long term wellbeing of the infant. Page 29 of 106

30 The maternity service in Powys is midwife led, which means that all care given is directed by the midwives. We plan, implement and give holistic care to all low risk women and share care with a consultant for those women who have any complications or medical problems. Powys Midwife Monitoring Intrauterine Growth Pregnant women in Powys have a routine ultrasound scan at around 12 and 20 weeks, as well as regular assessment of pubic symphysis to fundal height measurement from 25 to 28 weeks to monitor the growth of the baby. In 2010, Powys maternity services implemented customised foetal growth charts as a part of routine antenatal care, to identify small for gestational age babies who require referral for further investigation. This was following work with a 1000 Lives mini collaborative. Midwives have since received further training on the Growth Assessment Protocol Programme, to support the use of the customised growth charts and the appropriate referral for ultra sound scans. The impact of the customised growth charts is being evaluated through retrospective (postnatal) review of babies born with a low birth weight. If a baby s growth is not as expected, the mother is referred for a further ultrasound scan to a District General Hospital, where the baby s size, the liquor volume and the umbilical blood flow are measured. Where clinically indicated, the care of the mother is then transferred to a consultant obstetrician. Antenatal and Newborn Screening Antenatal screening is performed to detect serious conditions in the mother or baby, where there is an effective intervention available. Some conditions have treatment available either during the antenatal period or after the delivery of the baby. However, for conditions where preventative treatment is not available, women are provided with counselling to help them make an informed choice about the pregnancy. Policies, standards and protocols for antenatal screening are established by the Antenatal Screening Clinical Network, led by Antenatal Screening Wales within Public Health Wales. Antenatal screening is undertaken by Powys midwives, as part of routine antenatal care. In accordance with national guidelines, pregnant women in Powys are offered screening for hepatitis B, human immunodeficiency virus, syphilis, rubella, blood group and antibody testing and Down s syndrome. Screening for blood disorders such as sickle cell and thalassaemia is offered where there is an increased risk of the pregnant woman having an affected child. A foetal anomaly ultrasound scan is offered between 18 and 20 weeks. Further information on screening in pregnancy and the newborn can be found in reports presented to the Board of Powys teaching Health Board Page 30 of 106

31 ( For example, newborn babies aged between five and eight days undergo newborn bloodspot screening (the heel prick test ). The blood samples are screened for a range of rare and serious diseases which respond to early intervention, including congenital hypothyroidism, cystic fibrosis, phenylketonuria and medium chain acyl-coa dehydrogenase deficiency. In addition, in Powys, 99.1% of newborn babies underwent newborn hearing screening (between 1 April 2012 and 31 March 2013), the aim of which is to identify babies with hearing loss severe enough to cause disability. This coverage is above the minimum standard for this test of 95%. Midwives and health visitors in Powys have a central role in newborn screening by performing the test, ensuring timely results and organising repeat screening or follow up, where needed. Health visitors also help to organise screening for infants aged under one year, who transfer in from outside the UK, if there is no evidence of previous bloodspot screening or newborn hearing tests. Vaccination Advice to Pregnant Women In Powys, all pregnant women are given information by their midwife on influenza, pertussis (whooping cough) and the mumps, measles and rubella (MMR) vaccination and are supported to visit their GP for the vaccines where indicated. Powys midwives screen for rubella and inform women of the need for postnatal vaccine where indicated. In 2013/14, influenza vaccination uptake in pregnant women was 37.6% in Powys, compared with 43.7% across Wales. There are no confidence intervals available to determine if this difference is significantly different. A comprehensive action plan is in place to improve uptake in the 2014/15 season. Pertussis vaccination was started in 2012, following the largest outbreak of pertussis seen in the UK in a decade. Between 1 January 2012 and 31 August 2012, there were 4,791 confirmed cases in England and Wales. Whilst most cases were in adolescents and young adults, there were 302 cases and nine deaths in infants less than three months of age. In response, the Chief Medical Officer for Wales announced that pregnant women from 28 weeks onwards were to be offered pertussis vaccination to protect their newborn babies, through passive immunity. An audit of pregnant women at the time of delivery (McGowan A et al, 2014) demonstrated that 298 women from a total of 430 who gave birth over a five day period in Wales had received the pertussis vaccine (69.3%). In Powys, of the two women who gave birth during the five day period, both had received the pertussis vaccine (100% uptake). Smoking Cessation Evidence shows that smoking during pregnancy increases the risk of premature delivery, low birth-weight, stillbirth and sudden infant death syndrome (SIDS). Smoking during pregnancy also increases the risk of infant mortality by approximately 40% (NICE 2010). Smoking during pregnancy is strongly associated with a range of factors including young maternal age, social class and the smoking status of the woman s partner. For example, mothers Page 31 of 106

32 aged 20 years or under are five times more likely as those aged 35 years and over to have smoked throughout pregnancy. The midwifery service in Powys is now collecting information on smoking status at antenatal booking, as part of an online reporting tool. This data shows that in 2013/14, of 722 pregnant women who were seen at booking, 102 (14%) smoked, 550 were non smokers and in 70 cases, the smoking status was not known. This is work in progress - not all Powys maternities are currently captured on the system (for example, Office for National Statistics data records 1,171 Powys maternities in 2012). According to the Wales Infant Feeding Survey (2010), around a third of pregnant women who smoke continue to do so throughout their pregnancy, which is higher than other areas of the UK. No local data is currently available on the smoking status of pregnant women at delivery. Further, relapse rates are high amongst women who do quit smoking during their pregnancy, with most starting to smoke again within the first six months following delivery (NICE 2010). Smoking cessation services for pregnant women in Powys are provided through Stop Smoking Wales and Level 3 community pharmacy smoking cessation scheme. The local model offers increased choice and access for women wanting to quit smoking. In addition, in 2013/14, all midwives in Powys were trained to deliver tobacco brief interventions. Referral pathways to smoking cessation services have been clarified and all pregnant smokers are given information and offered referral to either a community pharmacy or Stop Smoking Wales. The Powys Public Health Team are leading further work around tobacco control, including working with midwives and health visitors, including Flying Start health visitors, to increase the number of clients who access local smoking cessation services. Healthy Weight A report by the Centre for Maternal and Child Enquiries (2010) highlighted that 6.5% of pregnant women in Wales have a BMI of 35 or more at any point of their pregnancy. The prevalence of maternal obesity was 5% across the UK. Pregnant women in Powys are weighed at booking and again at 36 weeks. If a woman s BMI is over 35 at booking, she is referred by the midwife to a District General Hospital for specialist obstetric advice. The pregnant woman continues to receive midwifery-led care, although delivery of the baby takes place at the local District General Hospital. The Powys healthy weight strategy and action plan includes further work to be led by maternity services to develop a toolkit to assist weight management during pregnancy. Mental Health Mental health and wellbeing of babies and children are inextricably linked to the mental health and wellbeing of their parents and in particular their mothers (Welsh Government 2012). There are long lasting effects of perinatal mental health problems on maternal health and child development (Welsh Government. 2011). The Together for Mental Health Delivery Page 32 of 106

33 Plan ( ) places emphasis on promoting good mental health in pregnancy, as well as early identification of mental health problems and antenatal interventions. The Plan emphasises that effective support for parenting including skills training can improve the mental health, behaviour and long-term life chances of children. In Powys, all midwives have received mental health first aid training, with the aim of improving mental health literacy and enabling midwives to respond to mental health crises. Midwives have also completed Maternal Mental Health: A Learning Programme for Midwives, designed by the All Wales Maternity Perinatal Mental Health Group. The purpose of the training is to help health professionals ask key questions to predict and detect women at risk of severe mental illness during pregnancy and childbirth. Health visitors also play a central role in assessing and identifying post-natal depression through their use of the Edinburgh Post-natal Screening Tool and onward clinical management. Related to this issue, routine enquiries for domestic abuse are undertaken with all pregnant women as part of antenatal care and again before a baby reaches eight weeks of age. Infant Feeding: Breastfeeding and Healthy Start There is robust evidence for the positive impact of breastfeeding on maternal and infant health; some of these effects extend significantly beyond the immediate postnatal period. Powys women have the highest breastfeeding rates in Wales. In 2004, 71.5% of babies were breastfed at birth in Powys, compared with 52.4% in Wales. By 2013, the rate had increased to 80.8% in Powys, significantly higher than the rate across Wales (55.9%) (figure 16). This data needs to be treated with caution, as completeness of breastfeeding data varies across Wales. In 2013, 17% of records in Wales had no breastfeeding status recorded at birth; it is hoped that new breastfeeding definitions and data recording processes introduced in September 2012 will improve data completeness. Page 33 of 106

34 Figure 16: % of babies breastfed at birth, 2013 % of babies breastfed at birth, 2013 Produced by Public Health Wales Observatory, using NCCHD (NWIS) Wales = 55.9% Betsi Cadwaladr Powys Hywel Dda ABM* Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea* Neath Port Talbot* Bridgend* Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport * Breastfeeding status is not recorded for a much larger proportion of births in some areas Source: Produced by Public Health Wales Observatory, using NCCHD (NWIS) Once a baby is born to a Powys woman, support is provided by midwives and health visitors to encourage and promote breastfeeding. Support provided to new mothers includes breastfeeding assessment, one-to-one support and signposting to local support groups and online support sites. It is recognised that the UNICEF Baby Friendly Initiative is a key determinant of population breastfeeding rates, as it underpins a systems approach to improving breastfeeding, ultimately supporting a change in culture. Powys has been awarded Level 2 of the scheme and is now working towards accreditation at Level 3, with the aim of achieving full accreditation by A network of breastfeeding groups and peer supporters has been established across Wales, with the aim of supporting mothers to continue breastfeeding and in particular to address inequalities in breastfeeding rates. There are currently six breastfeeding support groups in Powys, facilitated by local mothers and peer supporters and supported by local health professionals. The support groups are in Brecon, Llandrindod, Welshpool, Machynlleth, Page 34 of 106

35 Newtown and Llanidloes. The Welsh Breastfeeding Welcome scheme designates interested public venues as Breastfeeding Welcome, when there has been a commitment to providing a welcome for breastfeeding mothers. There are currently sixteen registered venues in Powys. Recommendation 1 Senior lead officers from Powys teaching Health Board should explore whether there are any opportunities to further develop and tailor support for pregnant smokers, based on lessons learned from the local breast feeding programme New mothers are also offered support by health visitors during weaning. Advice includes recommendations on starting solids, the importance of avoiding salt and sugar and the prevention of dental decay. Pregnant women and women with a baby under four years old are entitled to vouchers as part of the means tested Healthy Start Scheme. Vouchers can be used to buy cow s milk, fresh or frozen fruit and vegetables and infant formula milk at local retailers. Midwives and health visitors provide advice on the scheme. Women in receipt of Healthy Start food vouchers are also provided with coupons for free Healthy Start vitamins, formulated to help growth and development. Page 35 of 106

36 4 The Early Years Summary The early years are a period of rapid physical and emotional development. This chapter focuses on the importance of a range of interventions in the early years, including vaccinations, exposure to tobacco smoke, accidental injury, alcohol misuse and healthy eating. Oral health is addressed in chapter 5. The importance of partnership working and a multiagency approach is highlighted, with a specific focus on the role of health visitors, Flying Start and the Healthy Pre-Schools initiative. Introduction Early years are fundamental to the health and wellbeing of children in later life. The quality of experiences during these formative years play a significant role in shaping the life chances and abilities of the individual in later life (Welsh Government, 2011c). A child s physical, intellectual, emotional, social and behavioural wellbeing is strongly influenced by parental health, lifestyles and behaviour (Welsh Government, 2013). Key areas which are known to impact on the health of preschool children include exposure to tobacco smoke, dental decay and uptake of measles, mumps and rubella vaccination (Children and Young People s Wellbeing Monitor for Wales, 2011). Improving the Health of Children Under Five Years in Powys Vaccinations Vaccination saves lives. The World Health Organisation (WHO) estimates that worldwide over one hundred million children are now vaccinated each year and two and a half million child deaths are prevented each year due to vaccination. The World Health Organisation regards vaccination as a basic human right and the United Nations has prioritised improvements in vaccine uptake as key to reducing childhood mortality (United Nations, 2008). In the UK, vaccinations against a range of diseases (diphtheria, tetanus, polio, pertussis, Haemophilus influenzae type B, pneumococcal infection, rotavirus, measles, mumps, rubella and meningitis C) are provided to children at different ages, from two months onwards. In Powys, all pre-school vaccines are provided through GP practices. In Wales, the target uptake for childhood vaccinations is 95%. There has been an increase in the uptake of children s vaccinations in Powys between 2004 and For example, figure 17 shows the positive trend in routine pre-school vaccinations in Powys during this period. Page 36 of 106

37 Figure 17: Powys teaching Health Board trends in routine vaccinations Source: Vaccine Preventable Disease Programme, Public Health Wales. COVER 111 Table 2 summarises overall vaccination uptake rates in pre-school children in Powys for 2013/14. The table also highlights uptake rates in Wales and the number of additional children who would need to be vaccinated in Powys, in order to deliver the 95% vaccination uptake target at population level. In 2013/14, 87% of 4 year olds in Powys were up to date with their routine vaccinations, compared with 87.9% in Wales. Table 2: 2013/14 Wales and Powys Childhood Vaccination Uptake Rates Age Vaccinations Powys uptake % Wales uptake % Number needed to vaccinate in Powys to achieve 95% 1 year 5 in year Men C years MMR years PCV years Hib/MenC booster years MMR years 4 in Source: Public Health Wales Vaccine Preventable Disease Programme. COVER Annual Report Page 37 of 106

38 The Powys Vaccination Steering Group leads the co-ordination, implementation and monitoring of vaccination programmes in Powys. Its action plan is structured to increase local uptake rates to national target, including through enhanced follow-up of children who miss appointments and by providing feedback (of uptake data) to the key professionals involved in vaccination, including GPs, health visitors and school nurses. Figure 18 shows the proportion of children who were up to date with their routine vaccinations by four years by Health Board and the quintile of deprivation (by Lower Super Output Area) in which they live (2013/14). In Wales, uptake rates are highest in the most affluent communities, with a 5.2% difference in uptake between the least deprived quintile and the most deprived quintile in 2013/14 - a reduction from 2012/13, when the gap was 8.9% across Wales. However, in 2013/14, this gradient was not observed in Powys, although intelligence for the most deprived quintile has been suppressed due to small numbers. Figure 18: % of children who are up to date with routine immunisations by four years of age, by quintile of deprivation of the Lower Super Output Area in which they reside. Vaccine uptake is presented for children reaching their 4th birthday between 01/04/2013 and 31/03/2014 and resident on 01/05/2014. Source: Public Health Wales Vaccine Preventable Disease Programme. COVER Annual Report Page 38 of 106

39 Recommendation 2 Powys teaching Health Board should further explore the relationship between local vaccination rates and socioeconomic status, with support from Public Health Wales. Immunisation plans may need to be updated in the light of this review Exposure to Tobacco Smoke Tobacco smoke causes serious harm to the life, health and wellbeing of smokers and to non-smokers who are exposed to second-hand smoke (Welsh Government, 2011b). Evidence has shown that one of the strongest predictors of passive smoke exposure in children is the smoking status of parents and whether they smoke inside the home (Royal College of Physicians, 2012). The Welsh Health Survey 2012/13 found that 19% of Powys adults smoke, compared to the Wales average of 22%. One of the key aims of the Powys Tobacco Control Action Plan is to reduce exposure to second hand smoke, including a range of actions in relation to smoke free. Health visitors should raise the issue of smoking in the home with parents of young children. In addition, all health visitors are being trained in the Stop Smoking Wales smoking cessation brief intervention approach, providing them with an evidence based approach to discussing smoking, with the aim of triggering a quit attempt. Health visitors can also refer parents and other family members into smoking cessation services. Accidental Injury Accidental injury is one of the most common causes of death in children over the age of one in most European countries (European Child Safety Alliance, 2009). Children from the most deprived communities in Wales are the most likely to have an accident both within and outside the home (Welsh Government 2010). There is no age specific intelligence available on accidental injuries in children in Powys. Although the evidence base is variable, accidents can be prevented by increasing awareness, adapting the home environment and ensuring greater product safety. In Powys, information relevant to the age and stage of development of children is offered to all families at each health visitor contact. In order to develop this further, the health visiting team is working with Action for Children to develop an approach to address accidents inside and outside the home. Page 39 of 106

40 Alcohol Misuse Alcohol misuse by parents and carers can impact on the health and wellbeing of children and influence their future behaviours (Welsh Government, 2008). Alcohol brief intervention training is provided to healthcare and partner agency professionals who work with families, with the aim of developing skills to identify harmful drinkers and signpost to support and advice services that will enable behaviour change at an early stage. Healthy Eating Being overweight or obese in childhood has consequences for health in both the short and longer term. Childhood obesity is a risk factor for a number of chronic diseases in adult life including diabetes, heart disease, some cancers and osteoarthritis. Healthy eating habits in the years before school impact positively on growth, development and achievement in later childhood (Welsh Government, 2011b). Powys community dieticians deliver the Agored Cymru accredited community food and nutrition skills training course Nutrition Skills for Life to professionals from health, social care and third sector organisations who work with children and families in early years settings. The aim of the course is to support community workers to promote healthy eating and incorporate food and nutrition skills into their work and reach community groups who may not have the confidence to prepare and eat a healthy balanced diet. By training those who work closely with, and understand the needs of local people, the programme supports communities to learn more about healthy eating. In July 2014, the Nutrition Skills for Life programme, won the Promoting Better Health and Avoiding Disease award, as part of the annual NHS Wales Award. Recommendation 3 The Powys Healthy Weight Steering Group should review the scope and impact of its actions in preschool settings. This work may need to take due account of the outcome of the current health improvement review by Public Health Wales Powys Health Visiting Programme Health visitors deliver a vital role in improving the health and wellbeing of families with young children through assessing health needs and offering appropriate support. This includes information, support and advice to the family on key issues such as breastfeeding and weaning, developmental milestones, as well as referring to more specialist services when needed. Health visitors also provide information and advice on a range of healthy lifestyle Page 40 of 106

41 topics including mental health and wellbeing, diet and nutrition, safety, alcohol and substance misuse, smoking, vaccinations, oral health and contraceptive advice. Health visitors also provide support to families experiencing difficulties and facilitate access, for example, to parenting programmes. A Powys health visitor s view of her role: We are often the first point of contact for the family, we assess and then signpost to other professionals or resources such as paediatricians, Speech and Language Therapists, Dieticians, Occupational Therapists and GPs. We also liaise with early years settings and pre-school assessment units, Action for Children and Children s Services. Some families think we are there to check up on them, but it is much more about support and encouraging parents with good practice. Some parents just need a bit of extra confidence. A Powys mother of a two month old baby talking about the role of health visitors: As a new mum it s great to have the one-to-one support with home visits, but also to have the chance to chat with other mums and to meet as a group. It is important for the babies to socialise together and yet to also have expert advice on hand Flying Start Flying Start is a Welsh Government programme targeted at families with children under four years of age, living in the most deprived areas of Wales. The aims of Flying Start are to: Reduce the number of people with very poor parenting skills Reduce rates of criminal behaviour, truancy and drug use Foster higher employment, increased earnings and better qualifications at the end of schooling The programme includes the provision of free high quality childcare, parenting support, intensive health visitor support and support for early literacy (Welsh Government, 2012a). During 2013/14, the Flying Start programme operated in parts of Welshpool, Newtown, Ystradgynlais and Brecon. The programme has since been expanded to include areas of Llandrindod Wells. In overall terms, the programme aims to give children a flying start in life, by focusing on the early identification of need, in order to avoid intervention later in life. An evaluation report of Flying Start (Welsh Government 2013) showed that those in Flying Start areas had on average 5.7 more visits from the health visiting team than families in non-flying Start areas, as well increased take-up of parenting programmes and Language and Play. Families in Flying Start areas reported improvements in local services and greater satisfaction with childcare services. No statistically significant differences were found in outcomes relating to parenting or child development when comparing Flying Start and non Flying Start Page 41 of 106

42 comparison areas. There are numerous possible explanations for this, including that Flying Start has resulted in improved outcomes among the families in Flying Start areas, so that they are on par with those in less disadvantaged comparison areas. A wide range of professionals and practitioners are involved in delivering the programme in Powys, including health visitors, childcare staff, Barnardo s, Action for Children, the early language development team, community advisory teachers and the Flying Start administration team. Powys Flying Start is led and coordinated by the Children and Young People s Partnership. Powys Healthy Pre-school Scheme The Healthy and Sustainable Pre-school Scheme was introduced by Welsh Government in 2011, as an extension of the Welsh Network of Healthy Schools Schemes. In Powys, the scheme is overseen by the Wales Pre-Schools Providers Association, on behalf of the Public Health Wales. The scheme supports preschool settings to plan and implement actions to improve health and wellbeing. Participating preschool settings are assessed by the Wales Pre-Schools Providers Association against standards set out in Healthy and Sustainable Pre-School Scheme National Award Criteria (Welsh Government 2011). Pre-schools are assessed in the specific areas of: Nutrition and oral health Exercise and active play Environment and safety Hygiene Mental and emotional health Wellbeing and relationships Health promoting workplaces In Powys, settings receive direct support from Mudiad Meithrin (a voluntary organisation specialising in Welsh-medium early years provision), the Wales Pre-School Provider Association, Dyfodol Powys Futures (a voluntary organisation providing services to enhance the development and education of children and young people) and the Children and Young People s Partnership. The Powys Healthy Schools team have developed and sourced guidance and resources, as well as organising and delivering training on specific areas of work. The team held a conference Safety and the Environment, which included contributions from health visitors, police, fire and road safety services and Public Health Wales. In Powys, eighteen settings have been recruited and five are on the waiting list, exceeding the national target of recruiting fifteen settings to the scheme in Powys. Page 42 of 106

43 Recommendation 4 The Powys Children and Young People s Partnership should receive a comprehensive report on the Powys Healthy Preschools and Schools schemes on an annual basis, encompassing outcome measures Page 43 of 106

44 5 School Years Overview This chapter continues to explore the impact of lifestyle and preventive measures on the health and wellbeing of school-age children. Specific issues addressed in this section are healthy weight and physical activity, smoking and substance misuse, vaccinations, oral health and mental health and wellbeing. Sexual health is presented in Chapter 6 (Young People, 16 to 24 Years) of the report. Schools have a central role in promoting social, emotional and physical wellbeing. The role of the Healthy Schools Scheme in facilitating this is described. Introduction Healthy children are more likely to learn effectively; children who attend school regularly have better chances of maintaining good health. The direct contribution of educational attainment towards health status is equal to, if not greater than, the impact of income (Welsh Government, 2011). In Powys, 78% of children aged 11 to 16 years rate their health as excellent or good ; the rate is not significantly different from the rate across Wales (Health Behaviour of School Children 2009/10). Improving the Health of Children of School Age in Powys Healthy Weight, Physical Activity and Healthy Eating Obesity has been described as a worldwide epidemic. According to the UK Government s Foresight Report (2007), nearly 60% of the UK population may be obese by 2050, with diseases such as type 2 diabetes expected to increase by 70%, stroke by 30% and coronary heart disease by 20%. A range of individual and societal factors contribute to overweight and obesity - physiological, psychological, social and environmental. The national Child Measurement Programme (CMP) evaluates the population prevalence of underweight, overweight and obesity across Wales. The programme was first established in Wales in 2011 and is delivered in Powys by the school nursing service, which undertakes the measuring and recording of the heights and weights of all school children in reception year (four and five year old children). Findings from the 2011/12 and 2012/13 cohorts are now available. In 2011/12, 29.0% of Powys reception year children were overweight or obese; this level was not significantly different to the Wales rate of 28.2%. In 2012/13, 24.4% of reception year children in Powys were overweight or obese; again, the rate was not statistically different from the Wales average rate of 26.2% (figure 19). Of note, eligible records were collected during the academic year 2012/13; this criterion was waived in order to analyse the data from Powys. Page 44 of 106

45 Results therefore differ from those published in the Child Measurement Programme Report 2012/13. Figure 19: Percentage of children aged 4-5 years who are overweight or obese, Wales and health boards, Child Measurement Programme for Wales, 2012/13 Produced by Public Health Wales Observatory, using CMP data (NWIS) Wales= 26.2% Cwm Taf UHB ABM UHB Hywel Dda UHB Betsi Cadwaladr UHB Aneurin Bevan UHB Powys THB Cardiff and Vale UHB In 2012/13, a significantly lower proportion of girls in Powys were overweight or obese compared with Wales; there was no significant difference in the rate for boys in Powys compared to Wales (table 3). Table 3: Children aged 4-5 years who are overweight or obese, (%, with 95% confidence intervals) Girls Boys Powys 20.2% ( ) 28.3% ( ) Wales 25.6% ( ) 26.8% ( ) Source: CMP 2012/13. Public Health Wales Observatory Considering obesity specifically, in 2012/13, 11.2% of Powys reception year children were obese; the Wales average was 11.3%. In 2011/12, 12% of reception year children in Powys were obese, compared to 12.5% across Wales. These differences are not statistically significantly different. Intelligence on overweight and obesity in young people in other age groups is extremely limited. In 2009/10, the Wales Health Behaviour of School Children survey found that approximately one in five Welsh secondary school children (18%) aged 11, 13 and 15 years was overweight or obese, based on self reported height and weight. Page 45 of 106

46 Physical Activity in Children One of the aims of the 2011 Welsh Government Strategy Climbing Higher: Creating an Active Wales is to develop a physical environment which makes it easier for people to be more physically active through appropriately designed and maintained play areas, safe and attractive streets, pedestrian links, cycle paths and access to green spaces (Welsh Government, 2011d). For the five year period 2007 to 2011, Public Health Wales has reported that 40.3% of Powys children undertook physical activity for an hour or more each day, compared with 36% across Wales; this difference is not statistically significant (figure 20). Figure 20: % of children aged 4-15 who reported undertaking physical activity for an hour or more every day, Produced by Public Health Wales Observatory, using WHS (WG) & MYE (ONS) Wales = 36.0 Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan More recently, results from the Sport Wales School Sport Survey show that across Wales, the number of young people taking part in sport or physical activity three or more times a week has improved, from 27% in 2011 to 40% in Table 4 compares survey results for Powys and Wales. Overall, pupils in Powys tend to participate in more sport compared with pupils across Wales, although confidence intervals are not published alongside survey results. Table 4: Sport Wales School Sport Survey 2013 Powys Wales Average number of minutes of PE per week How much do you think PE lessons and school sport help you to have a healthy lifestyle? pupils responding a lot Percentage of pupils taking part in extracurricular sport in the /13 academic year Percentage of pupils who visited a sports or leisure centre in the 2012/13 academic year Percentage of pupils participating in extracurricular and / or club sport on three or more occasions a week Source: Sport Wales School Sport Survey p10 Participation rates in extracurricular sport tend to decrease in girls once they enter school year 8. At the same time, there is also a decrease in boys participating in sport frequently (at least once a week). As part of the School Sports Survey, Powys pupils were asked about the barriers to doing more sport and what would encourage them to participate more in Page 46 of 106

47 sports. The most frequent responses from both primary and secondary pupils were that they would participate more if they had more time, if they were able to go with friends, if there were more sports that suited them, if the clubs were easier to get to and if sports participation was cheaper. Healthy Eating In the Health Behaviour of School Children Survey (2009/10), 35% of 11 to 16 year olds in Powys reported eating fruit every day, compared with 32% across Wales. 41% reported eating vegetables on a daily basis compared with 32% in Wales. Figures 21 and 22 compare vegetable and fruit consumption for girls and boys in different countries and for Welsh Health Boards for 2009/10. In Powys, a higher proportion of girls than boys ate fruit and vegetables on a daily basis in Powys. As there are no confidence intervals available, it is not possible to determine if these differences are statistically significant. Figure 21: % of persons aged 11-16* who reported eating vegetables every day, 2009/10 Produced by Public Health Wales Observatory, using HBSC (WG) Males Females Estonia (lowest) Flemish Belgium (highest) HBSC average Scotland Ireland England Wales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan *Country level data only includes ages 11, 13 and 15. Page 47 of 106

48 Figure 22: % of persons aged 11-16* who reported eating at least one piece of fruit, daily, 2009/10 Produced by Public Health Wales Observatory, using HBSC (WG) Males Females Greenland (lowest) Denm ark(highest) HBSC average Scotland Ireland England Wales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan *Country level data only includes ages 11, 13 and 15. Tackling Overweight and Obesity in Young People In Powys, the prevention and management of overweight and obesity on an all-age basis is led by the Healthy Weight Steering Group, through the Powys Healthy Weight Action Plan, developed and agreed by local partner agencies including Powys County Council, Powys teaching Health Board and Public Health Wales. The Wales care pathway approach across the life course informed the action plan (figure 23). Figure 23: Wales Care Pathway Approach Page 48 of 106

49 Specific measures in the action plan for children and young people include achieving consistent messaging for children, young people and their families and increasing opportunities for school age children to take part in physical activity. MEND (Mind, Exercise, Nutrition, Do it) is a course sponsored by Welsh Government for families with children aged 7 to 13 years, whose weight is above the healthy range for their age and height. The programme helps children and families to manage their weight better and lead healthier lives. The course runs twice a week after school, as two hour sessions over a ten week period. MEND in Powys is co-ordinated by Powys County Council leisure services and is run in five sites (Ystradgynlais, Brecon, Llandrindod Wells, Newtown and Welshpool). Tobacco Control and Smoking It is estimated that there are 456 children aged 11 to 15 years who start smoking each year in Powys 1 (Hopkinson NS et al, 2013). Compared with children living in non smoking households, children who live with parents or siblings who smoke are nearly three times as likely to smoke (Leonardi-Bee J et al, 2011). Other important risk factors for smoking initiation in children include having friends and peers who smoke, the ease with which cigarettes are obtained, socioeconomic status and tobacco marketing. Uptake of smoking at an early age is associated with heavier smoking levels, higher levels of dependency and a lower chance of quitting and higher mortality (Royal College of Physicians, 2010). The Health Behaviour of School Children study demonstrated that there is no significant difference between self reported weekly smoking rates amongst 11 to 16 year olds in Powys 1 Page 49 of 106

50 (3% in boys and 5% in girls), compared with the rest of Wales (5% in boys and 7% in girls) (figure 24): Figure 24 % of year-olds who reported smoking at least once a week, 2009/10 Produced by Public Health Wales Observatory, using HBSC (WG) Males Females Armenia (lowest) Greenland (highest) HBSC average Scotland Ireland England Wales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Anuerin Bevan In Wales, smoking is more common amongst children aged 11 to 16 years from the most deprived backgrounds and amongst females (figure 25). 9% of children aged 11 to 16 years from less affluent families reported smoking compared with 5% of children from more affluent families. Smoking prevalence was highest amongst year 10 pupils (aged 14 to 15 years). Figure 25: % of persons aged who reported smoking at least once a week, stratified by Family Affluence Scale (FAS), Wales, 2009/10 Produced by Public Health Wales Observatory, using HBSC (WG) Males Females Persons FAS 1 (low) FAS 2 (med) FAS 3 (high) Year 7 Year 8 Year 9 Year 10 Year <0.5 < A key component of the Powys Tobacco Control Action Plan is to prevent children and young people from starting to smoke. Through the Tobacco Control Steering Group, key Page 50 of 106

51 stakeholders in Powys work together to achieve this by limiting access to tobacco products, de-normalising smoking, for example by working with families to prevent children from being exposed to smoking behaviour in the home and by delivering smoking prevention programmes in school settings. Substance Misuse As part of the Health Behaviour of School Children study, young people were asked how often they drank a range of alcoholic drinks including beer, wine, cider, spirits and alcopops. In Powys, 16% of 11 to 16 year olds reported consuming an alcoholic beverage on a weekly basis. 20% of boys reported that they drank alcohol at least once a week and 10% of girls drank alcohol weekly (figure 26). These rates are not significantly different from the Welsh average. Figure 26: % of persons aged 11-16* who reported drinking alcohol at least once a week, 2009/10 Males Fem ales Lowest (Iceland) Highest (Czech Republic) HBSC average Scotland Ireland England Wales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan *Country level data only includes ages 11, 13 and 15 Source: Produced by Public Health Wales Observatory, using HBSC (WG) Survey participants were also asked if they had used any illegal substances previously. 9% of male and female secondary school students in Wales reported having used some form of illegal substance in the previous year; Powys rates - 7% of boys and 6% of girls were not significantly different from the Wales position. Page 51 of 106

52 Figure 27: % of persons aged who reported using any illicit drug in the last year, 2009/10 Males Fem ales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Wales Source: Produced by Public Health Wales Observatory, using HBSC (WG) Working Together to Reduce Harm (2008) is the Welsh Government s ten year substance misuse strategy for tackling the harm associated with the misuse of alcohol and drugs. Nationally, an all Wales educational programme has been established and at local level Community Safety Partnerships are funded to commission treatment services. Area Planning Boards have been established to bring agencies together to plan and deliver substance misuse services, with a greater emphasis on health and social care need, rather than criminal justice aspects alone. Dyfed Powys Police employ three school liaison officers in Powys, who provide input across curriculum Key Stages 1 to 4 and cover issues around drugs and substance misuse, antisocial behaviour and community safety, with a focus on crime prevention and reduction. Vaccination for School Age Children School aged children in the UK are routinely offered vaccination against diphtheria, tetanus, poliomyelitis and meningococcal (group C) disease. Girls are also offered vaccination against the types of human papilloma virus (HPV) that most commonly cause cervical cancer. The UK routine vaccination schedule not only aims to protect individuals against disease, but by achieving high levels of uptake, the spread of the disease within a population is prevented and those who are unable to be vaccinated (for examples due to weakened immune systems) are protected. Vaccination uptake rates for 16 year olds in Powys and the number of additional children that need to be vaccinated to achieve national uptake targets are summarised in Table 5. Page 52 of 106

53 Table 5: Childhood vaccination uptake rates for Age Immunisations Powys uptake Wales uptake Uptake target Number needed to vaccinate in % % % Powys to achieve 95% 16 MMR years 16 years MMR in 1 teenage years booster In 2013/14, the uptake of three doses of HPV vaccine in Powys for girls aged 14 years (School Year 8 in 2012/13) was 77%, compared with 86% in Wales. The Powys Vaccination Steering Group has developed an evidence-based action plan to increase vaccination uptake amongst the target groups. Actions include undertaking an audit of HPV vaccination rates for high schools, proactively contacting parents of high school children who have not had two doses of Measles Mumps and Rubella (MMR) vaccine and exploring methods of increasing understanding of and engagement with teenagers on vaccination issues. The Wales Measles Outbreak Measles is a highly infectious viral illness. Complications include otitis media, pneumonia and more rarely encephalitis (inflammation of the brain). Measles infection can be prevented through two doses of the highly effective and safe measles, mumps and rubella (MMR) vaccine. Between November 2012 and July 1013, Mid and West Wales was affected by a large measles outbreak. In Powys, there were 96 measles cases reported between March 2013 and June Most cases were associated with school and pre-school settings. A MMR vaccination campaign was launched, with vaccines being administered via GP practices, school nursing teams and weekend drop-in sessions in Brecon and Newtown. In total, 2,998 MMR vaccines were given in Powys at non-routine ages during the outbreak. The response was undertaken in partnership with Powys County Council education department, leisure services, the Youth Information Service and the Children and Young People s Partnership. Schools played a central role by proactively raising awareness of MMR vaccination amongst parents and pupils. Community groups such as the Young Farmers and Girl Guides, the Powys Association of Voluntary Organisations and the Community Health Councils in Powys also helped to promote MMR vaccination. The measles outbreak was declared over in Powys in August Following the outbreak, a report of the measles outbreak affecting Mid and West Wales was produced. The Page 53 of 106

54 recommendations of this report have been included into the Powys Vaccination Action Plan, with the aim of preventing a future outbreak. Oral Health The main oral disease in childhood is dental caries - tooth decay. Tooth decay is preventable. Inequalities in oral health exist across Wales, with those in deprived areas suffering the most. There are Welsh Government targets to reduce inequalities in oral health: By 2020: to reduce the levels and burden of decay at age 5 among the most deprived quintile of the population to that recorded for the middle deprived quintile By 2020: to reduce the levels and burden of decay at age 12 among the most deprived quintile of the population to that recorded for the middle deprived quintile Tooth decay is a result of sugar in food and drink causing acid to be produced in the mouth. Dental decay can be prevented by limiting the frequency with which sugars are consumed, as well as by the action of fluoride on the surface of teeth. Fluoride can be introduced through toothpastes or drinking water. However, not all children brush their teeth and the water supply in Wales does not have adequate fluoride to prevent tooth decay. Welsh Government (2013) set out its position on water fluoridation in Together for Health: A National Oral Health Plan for Wales : The Welsh Government has no current plans to fluoridate water supplies in Wales. The Welsh Government acknowledges that in view of the poor dental health in Wales, the introduction of water fluoridation has the potential to deliver significant health gains and address health inequalities. Welsh Government have proposed maximising fluoride delivery at community level, through action on the use of fluoride toothpaste and varnish. Measuring Dental Decay in Children In Wales, dental epidemiological surveys are conducted in children at the age of five years and 12 years. The surveys include measuring preventable decay, active decay and inequalities in decay experience. Preventable decay The sum of decayed, missing and filled teeth (dmft) in five year olds and Decayed, Missing and Filled teeth (D 3MFT) in 12 year olds is a measure of the decay experienced by the average child. It is therefore the burden of disease which theoretically could have been prevented and is therefore key data for evaluation of efforts to prevent decay. Figures 28 shows the average number of decayed missing filled teeth (dmft) for children aged 5 years for Health Boards across Wales, comparing 2007/08 and 2011/12. Page 54 of 106

55 Figure 28: Average dmft for 5 year olds, Welsh Health Boards, 2007/08 compared with 2011/12 Source: Welsh Oral Health Information Unit In Powys, the average dmft for five year olds improved from 1.6 in 2007/08 to 1.3 in 2011/12, although this is not a statistically significant reduction. In addition, dmft levels were lower in Powys in 2011/12, compared with Wales average. Figure 29 shows that average number of Decayed, Missing and Filled teeth (D 3MFT) in 12 year olds surveyed in 2004/05, 2008/09 and 2012/13. It can be seen that average D 3MFT for Wales has reduced significantly from 1.1 to 0.8. There was a corresponding statistically significant reduction for Powys between the 2004/05 and 2012/13 survey years from 1.1 to 0.6. Page 55 of 106

56 Figure 29: Mean D 3MFT for 12 year olds, Welsh Health Boards, 2004/05 compared with 2008/09 and 2012/ D 3 MFT WALES Abertawe Bro Aneurin Bevan Morgannwg Betsi Cadwaladr Cardiff and Vale Cwm Taf Hywel Dda Powys Source: Welsh Oral Health Information Unit The proportion of five year old children in Powys with dental caries fell from 38.9% in 2007/08 to 34.8% in 2011/12, although this change was not statistically significant (figure 30). In 2011/12, fewer children in Powys experienced dental caries compared with Wales (41.4%). Figure 30: % of 5 year olds with caries experience (%dmft>0), Welsh Health Boards, 2007/08 compared with 2011/12 Source: Welsh Oral Health Information Unit Page 56 of 106

57 Figure 31 shows a statistically significant reduction in the proportion of 12 year old children experiencing decay between 2004/05 and 2012/13 across Wales (from 45.1% to 36.0%) and Powys (from 43.9% to 29.1%). Figure 31: % of 12 year olds with caries (%D 3MFT>0), 2004/05 compared with 2008/09 and 2012/ %D 3 MFT> WALES Abertawe Bro Morgannwg Aneurin Bevan Betsi Cadwaladr Cardiff and Vale Cwm Taf Hywel Dda Powys Source: Welsh Oral Health Information Unit Active decay Active decay is measured by the number of decayed teeth that children have. The changes for decayed teeth are less prominent than those experienced for preventable decay. Active decay means that the child is at risk of pain and infection, as well further loss of tooth tissue. Between 2007/08 and 2011/12, there was a reduction in the average decayed teeth in five year olds in Powys from 1.2 to 0.9, although this change was not statistically significant (figure 32). Page 57 of 106

58 Figure 32: Average dt for 5 year olds, Welsh local health boards, 2007/08 compared with 2011/12 Source: Welsh Oral Health Information Unit Between 2004/05 and 2012/13, there was no statistically significant reduction in the average decayed teeth (D 3T) in 12 year old children in Powys (figure 33). Figure 33: Average D 3T for 12 year olds, Welsh Health Boards, 2004/05 compared with 2008/09 and 2012/ D 3 T WALES Abertawe Bro Aneurin Bevan Morgannwg Betsi Cadwaladr Cardiff and Vale Cwm Taf Hywel Dda Powys Source: Welsh Oral Health Information Unit Page 58 of 106

59 The Oral Health and Dental Service Improvement Plan for Powys teaching Health Board, was approved by the Board in February Key challenges identified in the Plan include addressing inequalities in oral health and targeting oral health improvement programmes and dental services in a rural area and focusing on improving child dental health to develop meet Welsh Government targets. The aims of the Plan are to: Reduce oral health inequalities and improve oral health Improve access to the full range of dental services Improve quality of dental services Empower people to improve and maintain their own oral health Improve the patient experience Provide value for money Further information on the Oral Health and Dental Service Improvement Plan for Powys teaching Health Board is available at: In Powys, 67% of children aged 11 to 16 years reported brushing their teeth more than once a day (Health Behaviour of School Children, 2009/10), compared with 71% of children across Wales. 64% of the resident population of Powys attended an NHS dentist at least once in the 24 month period between April 2011 to March 2013, compared with 58% in Wales as a whole. Attendance rates were high in children, with 51.4% of 0 to 5 year olds, 78% of 6 to 17 year olds and 77% of 13 to 17 year olds attending an NHS dentist at least once (Powys teaching Health Board 2013). These rates, particularly in the 0 to 5 year olds, are closely related to deprivation. Children residing in the most affluent areas attended an NHS dentist at a higher rate than those in the most deprived areas. In other Health Board areas, a dip in access rates in 18 to 24 year olds was experienced, but in Powys, the access rate increased to 86.5%, the highest rate of all age groups. These figures somewhat underestimate dental attendance, as they do not include children and adults attending Community Dental Service clinics or private clinics. Designed to Smile is a national oral health improvement programme to improve the dental health of children in Wales. It aims to reduce the inequality in dental health throughout Wales and is funded by the Welsh Government. The scheme is delivered by the Community Dental Service in schools and nurseries in some of the most disadvantaged communities, where chronic tooth decay is most prevalent. In Powys, the focus is on F ying Start and Communities First pre-school settings, with the scheme linking closely with the Healthy Schools programme, child-minding settings and special needs colleges. The programme includes tooth brushing activities, healthy eating and drinking advice, in addition to dental screening. The number of Powys settings taking part in Designed to Smile in 2013/14 was 32, compared with 34 settings in 2012/13 (the drop in settings is due to school mergers), 29 settings in 2011/12 and zero in 2009/10. In 2013/14, 2,118 children (91.5% of children in participating settings) up to Pre-school Year 2 (children aged 6 to 7 years) participated in supervised tooth brushing at their nursery or school, as did 150 children in Years 3 to 6 (97.4% of children in participating settings). Additionally, 1,762 (82%) children up to Year 2 and 1,315 (95%) children in Years 3 to 6 in participating settings received oral health Page 59 of 106

60 promotion. As part of Designed to Smile, schools are visited every six months and the application of fluoride varnish is offered to children up to and including Year 2. In 2013/14, one application of fluoride varnish was applied to 782 children and two applications were applied to 200 children, which is an uptake of 70% of all children who were offered the intervention. Recommendation 5 Powys teaching Health Board should further explore and address local inequities in the uptake of NHS dental services amongst children and young people Emotional and Mental Wellbeing As this report has already highlighted, social wellbeing (having good relationships with others), emotional wellbeing (being happy and confident) and psychological wellbeing (being autonomous and resilient) provide the foundation for educational attainment and healthy behaviours, as well as helping to prevent mental ill health or behavioural problems (NICE, 2013). Young people who report low levels of satisfaction with life are less healthy and are more likely to be excluded from social activities and education (Welsh Government, 2011d). However, limited data related to emotional wellbeing is available, particularly for children and young people. Data available (Public Health Wales Observatory 2013) shows that in Powys: 88% of children aged 11 to 16 years reported having three or more close friends of the same gender, similar to the rate across Wales (89%) 32% of 11 to 16 year olds reported being bullied in the previous couple of months; in Wales this was 28%. A greater proportion of boys (38%) than girls (27%) reported having been bullied Around 1,700 Powys children aged 5 to 16 years are estimated to have a mental health disorder 84% of young people aged between 11 and 16 years of age rate themselves as satisfied with their lives (scored six or higher on self rated quality of life), compared with 83% in Wales. Scores were higher amongst boys (87%) than in girls (80%) (Figure 34) Page 60 of 106

61 Figure 34: % of persons aged scoring six or higher on self rated quality of life, 2009/10 Produced by Public Health Wales Observatory, using HBSC (WG) Males Females Turkey (lowest) Netherlands (highest) HBSC average Scotland Ireland England Wales Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan In Powys, Incredible Years and Kooth are examples of programmes which aim to improve childhood resilience and wellbeing. In addition to these, KiVa, a school based anti-bullying programme, is being piloted in Powys. Further work is underway to map current mental health and wellbeing services provided to children and young people, and identify effective interventions to address any gaps and promote resilience. Incredible Years The Incredible Years programmes are courses for parents, children and teachers, aimed at reducing aggression and behaviour problems in young children. In Powys, Incredible Years is delivered in various forms, including one to one support in the home, in schools, by childcare staff and as a parent programme (figure 35). For example, the parent programme supports parents at an early stage to develop positive coping skills to prevent behavioural problems in their children. Page 61 of 106

62 Figure 35: Incredible Years programmes in Powys The programme is designed to reduce family breakdown, reduce the number of children who enter the care system or who are excluded from school and to prevent emotional, social and behavioural difficulties. In Powys, Incredible Years is jointly funded through the Children and Young People s Partnership and delivered in partnership with Bernardo s Cymru. The programme was awarded the national NHS Wales Award in 2012, in the category of Working Seamlessly Across Organisations. Participating schools have reported a reduction in pupil conduct problems, hyperactivity and teacher stress. The benefits of the programme have been noted in Estyn inspections of Powys schools. Kooth Kooth is a free, on-line counselling and referral service, available to all 11 to 25 year olds in Powys. The service is commissioned by the Children and Young People s Partnership, with funding from Welsh Government. Services provided by Kooth include moderated message boards and blog facility and accessible information on a range of issues faced by young people. Kooth provides a safe online environment where young people can obtain advice and support with issues causing them stress, hardship or embarrassment. It also provides access to up to date information about local services, events and news. Topics frequently Page 62 of 106

63 raised through Kooth include problems at home and school, alcohol and drugs, sexual health and sexuality, anxiety, eating disorders and relationships. The on line counselling service has been complemented by a face to face counselling service, provided by Xenzone, which also provides Kooth. Young people can self-refer for face to face counselling via Kooth and use online support whilst waiting for an appointment. KiVa KiVa is an evidence based antibullying program which aims to prevent bullying and tackle bullying effectively when it does occur. KiVa was developed in Finland and it has been implemented in Netherlands, Estonia, Italy, and Wales. KiVa is a school based programme and includes both universal actions, which are directed at all students and are aimed at preventing bullying and indicated actions, which are used when bullying has been identified. Healthy Schools The National Institute for Health and Care Excellence (2009) has highlighted the importance of education establishments in providing an environment which fosters social and emotional wellbeing, equipping young people with the knowledge and skills to learn effectively and prevent behavioural and health problems. The World Health Organisation defines a healthy school as one that is characterised by constantly strengthening its capacity as a healthy setting for living, learning and working. The Wales Healthy Schools Scheme is led by Public Health Wales and is a partnership between health and education, which aims to improve pupil and staff health, linked to the development of learning. The scheme provides a structured approach for schools to promote and influence the health of the whole community through its organisation, ethos and environment. Schools involved in the scheme are engaged and supported in a range of activities, from school nutrition and peer mentoring, to school councils developing policies and initiating change as part of the school improvement process. The scheme encourages parents to engage in programmes which will benefit children s health and wellbeing, such as free school meals for eligible children. Participating schools work to achieve standards within seven themes: Page 63 of 106

64 Food and fitness Mental and emotional health and wellbeing Personal development and relationships Substance use and misuse Environment Safety Hygiene The Powys healthy schools team supports schools to achieve the five phases of the Welsh Government awards over a period of time (typically seven years), with the aim of working towards and attaining the National Quality Award (NQA). There are currently two national targets for the NQA; by March 2015: 1) 95% of Powys Schools to achieve the NQA Phase 3 or above. As of July 2014, 93% of Powys schools have achieved the Phase 3 Award. Locally, the target is to ensure a further three schools attain the Phase 3 award by March 2015; this is on course for achievement 2) To contribute to the national target that 5% of all maintained schools achieve the NQA. By July 2014, 4% of Powys schools have achieved the full NQA To achieve the NQA, a school needs to demonstrate that it is firmly committed to an approach which develops the whole school as a health promoting workplace and that it is thinking health as a matter of routine. However, local consultation with Powys schools highlighted that schools lacked the confidence to apply for the NQA award. This feedback resulted in the development of the Powys Excellence Award, which is based on the NQA criteria and provides schools with a stepping stone towards the NQA. Up to April 2014, six schools had successfully achieved the Powys Excellence Award. Further information can be found on the scheme s web site: Page 64 of 106

65 6 Young People (16 to 24 Years) Summary This chapter highlights the impact of educational attainment, further education and employment opportunities on reducing poverty in young people. There is a focus on risk behaviours in young people; smoking, alcohol consumption, sexual health, obesity and mental health. Where available, intelligence is presented on each of these topics. Actions in place to improve the health and wellbeing and life chances for young people are also described. Introduction Overarching determinants of the health and wellbeing of young people have been described earlier in the report. Educational attainment is a key determining factor of future life opportunities. Welsh Government (2012) has highlighted the importance of educational attainment in helping to lift people out of poverty and has made a commitment to raise aspirations, improve standards in education and increase skill levels. Further intelligence on educational attainment in Powys is available at: Welsh Government Statistics and Research: My Local School: My Local Council: Factors particularly associated with youth poverty are living away from the parental home, living alone, being a parent and unemployment (Iacovou M and Aassve A, 2006). Related to this, in 2004, 4.4% of Year 11 school leavers in Powys were not in education, employment or training, compared to 7% across Wales; by 2013, this figure had improved to 2.7% in Powys, lower than the Wales rate of 3.7% (Figure 36). It is not possible to determine if these differences are statistically significant. Page 65 of 106

66 Figure 36: Source: Powys Children and Young Peoples Partnership, using data from Careers Wales Figure 37 compares the proportion of Year 11 school leavers known not to be in education, employment and training for all Local Authorities in Wales in This shows that the rate in Powys (2.2%) is significantly lower than Wales (4.2%). Page 66 of 106

67 Figure 37: % of year 11 school leavers known not to be in education, employment or training (NEET), 2012 % of year 11 school leavers known not to be in education, employment or training (NEET), 2012 Produced by Public Health Wales Observatory, using Careers Wales (StatsWales) Wales=4.2% Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Source: Produced by Public Health Wales Observatory, using Careers Wales (StatsWales) In overall terms, based on the 2011 Census, 12% of 16 to 24 year olds were unemployed in Powys, which is lower than the Wales rate of 15.7%. Preventing Young People from Starting to Smoke At the time of writing, the most recent intelligence from the Welsh Health Survey shows that 25.5% of 16 to 24 year olds in Powys report being a smoker (figure 38). This rate is not significantly different from the Wales rate of 26.1%. The Powys Tobacco Control Action Plan has been described earlier in this report. Page 67 of 106

68 Figure 38: % of persons aged who reported currently being a smoker (daily or occasionally), Produced by Public Health Wales Observatory, using WHS (WG) & MYE (ONS) Wales = 26.1 Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Reducing the Harmful Impact of Alcohol Alcohol can have a substantial negative impact on the health and wellbeing of young people. The consequences can be immediate (for example accidental injury) and medium and long term (for example obesity, unplanned pregnancy and liver disease). Many factors, including alcohol advertising, price, availability and wider public attitudes towards alcohol impact on alcohol use in young people. People who start drinking at an early age are more likely to drink more frequently, in greater quantities and are also more vulnerable to developing alcohol problems in later life, than those who start drinking alcohol at an older age (Welsh Government, 2011d). In Powys, 50% of males and 39% of females aged 16 to 24 years report drinking above current daily guidelines (males 4 units, females 3 units) on the heaviest drinking day in the past week. Among this age group, 37% of males and 30% of females reported binge drinking (males over 8 units and females over 6 units) on the heaviest drinking day in the past week and 26% of males and 21% of females reported very heavy drinking (males over 12 units, females over 9 units) on the heaviest drinking day in the past week (Welsh Health Survey ). A comparison with UK alcohol sales data suggests that surveys, including the Welsh Health Survey, underestimate alcohol consumption and only represents 60% of alcohol sold (Public Health Wales, 2014). The Substance Misuse Strategy for Wales (Welsh Government, 2008) outlines key actions to address substance misuse amongst children and young people, including targeting older children and young people through schools as well as outside school settings. Evidence also shows that preventing underage alcohol sales impacts positively on alcohol misuse (NICE 2010). Page 68 of 106

69 As an example of the approach being taken in Powys, the Brecon Community Alcohol Partnership (B-CAP) was established in April 2012 and includes of a range of partners including schools, the police, trading standards, licensing teams and local retailers. B-CAP aims to tackle underage drinking and has developed actions based on a range of local data and public perception surveys. These include: Awareness raising: through social media sites including Facebook and Twitter, the development of a website and promotion at community venues and events via posters and leaflets. The group has also worked with schools by providing resources for staff, as well as guidance for parents and carers Diversionary activities : including the development of a youth cafe, with young people involved in its design and delivery. Also included are drug and alcohol workshops, arts projects, cooking lessons and reduced cost entry to the leisure centre in Brecon Enforcement: provision of training to on- and off-license staff around tackling alcohol availability, including the introduction of the Challenge 25 scheme to provide a consistent approach to tackling availability of age-restricted products, particularly alcohol. Bar runners with Can you prove your age were also designed for licensed premises B-CAP has been evaluated using a range of short, medium and long term measures, as well as stakeholder questionnaires and a public perception survey. The public perception survey of young people and local residents showed that both groups were concerned about the impact of underage drinking on anti-social behaviour. Survey participants were asked where they believed young people obtained alcohol from. 80% of residents believed that young people sourced alcohol from older friends, whereas only 10% of young people agreed with this perception. 65% of young people reported that they obtained alcohol from parents or guardians. A survey of licensed retailers indicated that 90% believed that the B-CAP had probably or definitely had a positive impact on underage drinking in Brecon. Retailers also reported that the scheme had helped to address issues such as stealing alcohol and underage alcohol purchasing. Further information on B-CAP is available on Youtube Sexual Health Sexual health is an important part of physical and mental health and wellbeing. The consequences of poor sexual health can be serious and include unplanned pregnancy and avoidable morbidity from sexually transmitted infections. Most teenage pregnancies are unplanned and just under half of these pregnancies in under 18 year olds end in termination of the pregnancy (Office for National Statistics 2013). Within Page 69 of 106

70 the UK, Wales has consistently had a higher rate of conceptions amongst the 15 to 19 year old population than England. In 2013, the Office for National Statistics highlighted that teenage conceptions in 2011, for both England and Wales, were at the lowest level since In Powys in 2012, there were 46 conceptions in under 18 year olds, of which 52.2% led to a planned termination of pregnancy; there were six conceptions in under 16 year olds. Figure 39 compares teenage conception rates between England, regions in England, Wales, Welsh Health Boards and Local Authorities. Conception rates for under 16 and under 18 year olds in Powys are not statistically significantly different from Wales. Figure 39: Teenage conceptions, rate per1,000 females, England regions, Wales health boards and local authorities, 2012 Produced by Public Health Wales Observatory, using conceptions data (ONS) Under 16 Under 18 Under 16 Under 18 Wales = 5.6 Wales = 30.8 England North East North West Yorkshire and the Humber East Midlands West Midlands East of England London South East South West Betsi Cadwaladr Powys Hywel Dda* Abertawe Bro Morgannwg Cardiff and Vale Cwm Taf* Aneurin Bevan* Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion* Pembrokeshire Camarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil* Caerphilly Blaenau Gwent Torfaen Monmouthshire* Newport Rates for females under 16 are per 1,000 females aged 13-15; rates for females under 18 are per 1,000 females aged *Rates based on counts of less than 5 have been suppressed; secondary suppression has been applied where necessary Page 70 of 106

71 Figure 40 shows that conception rates in under 18 year olds in Powys are below Welsh average and have fallen since 2005; however as no confidence intervals are presented, it is not possible to determine if this change is statistically significant. Figure 40: Under 18 conception rates, 2005 to 2012 Source: Conception and Vital Statistics, Office for National Statistics in Welsh Government Local Area Summary Statistics Powys. In common with some other rural areas in Wales, rates of sexually transmitted infections (Chlamydia and gonorrhoea) are lower in Powys than the Welsh average (figure 41). As no confidence intervals are available, it is not possible to determine whether this difference is statistically significant. For a number of reasons, it is likely that there is under-reporting of sexually transmitted infections for Powys residents. Page 71 of 106

72 Figure 41: Gonorrhoea and Chlamydia rates in persons aged by area of residence, rate per 1,000 population Betsi Cadwaladr Powys Hywel Dda* ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire* Carmarthenshire* Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Gonorrhoea (annual Positive test (%) average ) Gonorrhoea Chlamydia Wales* = Chlamydia (2011) Wales* = 31.4 * Data from clinics in Carmarthenshire and Pembrokeshire are not currently available via SWS so the figures presented represent only residents who have visited clinics elsewhere. Please note that completeness on reporting of area of residence and coding of diagnosis is variable across clinics and so results should be interpreted with caution Source: Produced by Public Health Wales Observatory, using SWS data provided by CDSC (PHW) and MYE (ONS) As part of the 2009/10 Wales Health Behaviour of School Children survey, year 11 pupils (aged 15 to 16 years) were asked two questions related to sexual behaviour - whether they had ever had sexual intercourse and the use of contraceptives. In Wales, 38% of girls and 28% of boys reported having had sexual intercourse. When asked about contraception method(s) they or their partner had used the last time they had sex, 79% of girls and 85% of boys in Wales reported using a condom. There are a range of initiatives in Powys which aim to improve the sexual health and wellbeing of young people. Many of these are undertaken in partnership between midwives, school nurses, health visitors, the Healthy Schools Scheme and Powys County Council. APAUSE (Added Power and Understanding in Sex Education) APAUSE is a sex and relationships educational programme for secondary schools, which was developed by the Department of Child Health at the University of Exeter. The programme s aims are to improve young people s knowledge, attitudes and behaviour around sex and relationships and raise confidence and self esteem. An evaluation of the Page 72 of 106

73 programme (Blenkinsop et al, 2004) found that it had a positive impact on pupil knowledge and attitudes towards sex. Powys is the only Local Authority area in Wales where APAUSE is delivered. In Powys, APAUSE is funded by the Children and Young People s Partnership and is delivered through the Powys Healthy Schools Scheme, with support from school nursing and education. Progress reports are presented to the Children and Young People s Partnership. Of the 13 high schools in Powys, 12 are currently delivering the programme. Empower to Choose The Wales Empower to Choose programme is led by Public Health Wales and was launched to reduce rates of repeat teenage conceptions through the provision of education and awareness raising around long-acting reversible contraception (LARC). Within Powys, Empower to Choose is being delivered in primary care settings, with GP surgeries providing long-acting reversible contraception during the postnatal period or following a termination of pregnancy. The project targets vulnerable groups, including looked after children, care leavers and young women using substance misuse services. Emergency Hormonal Contraception In Powys, emergency hormonal contraception is accessed through GP practices and community pharmacies. During 2012/13 there were 33 consultations for emergency hormonal contraception at community pharmacies amongst 13 to 15 year old girls. Page 73 of 106

74 C-Card The Sorted C-Card scheme was launched in 2012 across a range of settings in Powys and is led and managed by the Powys County Council Youth and Family Information Service. The scheme aims to ensure that young people under 25 have easy access to sexual health advice and support from trained youth workers and health professionals (school nurses) and if indicated, access to contraception. During 2012/13, the C-card scheme received 830 contacts from its target population. In addition, 907 young people were seen by youth workers in the Young People s Village at the Royal Welsh Show in July 2012, with 2,520 condoms being issued. Recommendation 6 The Powys teaching Health Board Public Health Team should lead a needs assessment of local sexual health services during 2015/16. This should encompass services provided and commissioned by the Health Board, to ensure effectiveness and value for money Overweight and Obesity Children and young people who are overweight or obese are more likely to be overweight or obese in later life (Biro FM et al 2010). 30.4% of Powys 16 to 24 year olds are overweight or obese, which is not significantly different from the Welsh average of 31.4%. The Powys Healthy Weight Action Plan has been described earlier in this report. Figure 42: % of persons aged who are overweight or obese, Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Wales = 31.4 Source: Produced by Public Health Wales Observatory, using WHS (WG) and (MYE (ONS) A significantly higher proportion of 16 to 24 year olds in Powys report undertaking 30 minutes of moderate / vigorous physical activity on 5 or more days (49.5%) compared with Wales (37.3%). Page 74 of 106

75 Figure 43: % persons aged who reported undertaking 30 minutes of moderate or vigorous physical activity on 5 or more days, Produced by Public Health Wales Observatory, using WHS (WG) & MYE (ONS) Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Wales = % of young people in Powys meet fruit and vegetable consumption guidelines, not significantly different to the position in Wales (31.0%). Figure 44: % of persons aged who reported eating five or more portions of fruit and vegetables the previous day, Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Wales = 31.0 Source: Produced by Public Health Wales Observatory, using WHS (WG) and MYE (ONS) Mental Health and Wellbeing Mental health is an integral part of overall health and wellbeing. Mental health and wellbeing are influenced by individual attributes such as physical health, as well as by social circumstances and the environment in which people live (World Health Organisation, 2012). At a population level, factors that contribute to better mental health and wellbeing include adequate housing, vibrant communities, healthy schools and workplaces and nurturing relationships. Factors that increase the risk of poor mental health include poverty, abuse, social isolation, bullying, overcrowding and unhealthy working environments (Welsh Government, 2012). Mental illness has a significant impact on life expectancy and is a cause of health inequalities; those with mental health problems are more likely to have fewer qualifications, have lower incomes and be more likely to be homeless. People with poor mental health or mental illness are at an increased risk of poor physical health, which is partly explained by higher levels of smoking, alcohol consumption, drug misuse and lower levels of physical activity (Welsh Government, 2012). Page 75 of 106

76 Over a ten year period (2002 to 2011), there were ten suicides in young persons aged 15 to 25 years in Powys. The suicide rate in Powys for this period was not significantly different from the rate for Wales (figure 45). Figure 45: Suicide mortality rates per 100,000 population, persons aged 15 to 24, Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Wales=8.6 Age-specific rate ( Number Suicide and self-harm prevention has been identified as priority in a number of national plans including Talk to Me', the Welsh Government s 2008 national plan to reduce suicide and self harm. Talk to Me recognised the need for a change in culture around mental health issues. Welsh Government also supports Youth Mental Health First Aid, a training programme for those working with young people, providing knowledge, skills and confidence to help a young person in mental distress. This is a two day course for professionals and gives an overview of mental health and ill-health, also highlighting access to a range of support and treatment interventions. Child and Adolescent Mental Health Services are involved in delivery of the programme in Powys. Page 76 of 106

77 7 Protecting Children from Harm Introduction Following Lord Laming s report into the death of Victoria Climbie, the Children Act 2004 required all Local Authorities across England and Wales to set up a Local Safeguarding Children Board (LSCB). The task of each LSCB was to safeguard and promote the welfare of children and young people in its area. From October 2006 all Welsh Authorities were required to set up a LSCB. LSCBs had a legal duty to make sure that keeping children safe were a priority for everyone. Powys LSCB has been responsible for coordinating local arrangements to safeguard and promote the welfare of children across Powys. Powys LSCB included representatives of all statutory and voluntary agencies in Powys, working with children and their families. In 2011 the Minister announced significant changes to the running and structure of LSCBs, with LSCBs moving to regional arrangements. As a result, the number of LSCBs across Wales has reduced from 22 to six. Powys joined the Mid and West Wales Regional Safeguarding Board, which consists of Powys, Carmarthen, Ceredigion and Pembrokeshire. CYSUR, as from 30 June 2014, delivers the Safeguarding Children Board functions across the Mid and West Wales region. CYSUR means reassurance in Welsh and is an acronym for Child and Youth Safeguarding and Unifying the Region. Local arrangements continue to be in place for Powys through the Powys Local Operational Group for Safeguarding. Membership of this group includes representatives from statutory and voluntary agencies. The objectives of CYSUR and Powys Local Operational Group for Safeguarding are: To protect children within its area who are experiencing, or at risk of, abuse, neglect or other kinds of harm To prevent children within its area from becoming at risk of abuse, neglect or other kinds of harm It must seek to achieve its objective by coordinating and ensuring the effectiveness of what is undertaken by each person or body represented on the Board (Social Services and Well-being (Wales) Bill (section 135, 1 and 3)) Page 77 of 106

78 Case Study - "Eat Carrots. Be Safe from Elephants" - Powys Junior Local Safeguarding Children Board Children and young people in Powys are represented on the Local Safeguarding Children Board through a group called Eat Carrots. Be safe from Elephants. Membership of the group is 11 to 18 year olds living in Powys. Members are drawn from all sectors of the community including mainstream and special schools, young people living away from home, youth clubs and the Young Farmers. The group meets during the school holidays and is consulted on issues, as well as being able to bring issues to the attention of the Safeguarding Children Board. Specific tasks of the groups include discussing safeguarding issues such as bullying, cyber bullying, internet abuse, domestic abuse and child protection. Further information is available at: Children In Need and Children on the Child Protection Register As defined by the Children Act 1989, children in need are those who are in need of further support from social services (Section 17, (10)). Under this Act, Local Authorities have a duty to provide services to safeguard and promote the welfare of children in need. In March 2013, there were 225 per 10,000 children in need in Powys, compared with a rate of 296 per 10,000 across Wales (0 to 17 year olds). However, as confidence intervals are not included for the data presented, it is not possible to determine if the difference is significantly different. Page 78 of 106

79 Figure 46: Rate per 10,000 population of children in need aged 0 to 17 (excluding unborn children), March 2013 Rate per 10,000 population of children in need aged 0-17 (excluding unborn children), March 2013 Produced by Public Health Wales Observatory, using Children in Need Census (WG) & MYE (ONS) Wales = 296 Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Source: Produced by Public Health Wales Observatory, using Children in Need Census (WG) and MYE (ONS) Figure 47 shows that the number of children in need in Powys has reduced between 2009 and 2014, although it not possible to determine if this difference is statistically significant. Figure 47: Source: Powys Children and Young People Partnership Page 79 of 106

80 Child protection registers are held by Local Authorities. A child is placed on a child protection register if s/he is deemed to be at continuing risk of physical, emotional or sexual abuse or neglect and for whom there is a Child Protection Plan. All children whose names are placed on the Child Protection Register have a Child Protection Plan to ensure that the risks are managed appropriately. This is an agreed plan which identifies areas of concern, how risks will be addressed and who will be responsible for implementation. Child Protection Plans are reviewed at Child Protection Conferences. Child protection registers and plans do not measure the incidence of mistreatment, but give an indication of scale. There is research evidence that abuse and neglect are both underreported and under-recorded (NSPCC). Figure 48 shows the reasons for children being placed on the child protection register; in the majority of cases, children are placed on the register due to emotional abuse or neglect. Figure 48: Percentage of children on the child protection registers in Wales, as at 31 March 2013, by category of abuse Source: Welsh Government Statistical Bulletin. Local authority child protection registers Wales, Figure 49 shows that there has been an increase in the number of children placed on the child protection register in Wales between 2002 and 2013, although it is not possible to determine if this is statistically significant. Page 80 of 106

81 Figure 49: Number of children on child protection registers in Wales, at 31 March Source: Welsh Government Statistical Bulletin. Local authority child protection registers Wales, However, between 2010/11 and 2013/14, there has been an overall decrease in the number of children placed on the child protection register in Powys (figure 50), which is likely to be due to improvements in care planning and effective interventions with families (Powys County Council 2014). Figure 50: Number of children placed on the protection register in Powys Source: Powys County Council Director s Report Figure 51 compares the child protection registration rate between Health Boards and Local Authorities in March As confidence intervals are not included for the data presented, it is not possible to determine if the observed rate in Powys is significantly different to the rate for Wales or other areas. Page 81 of 106

82 Figure 51: Rate of children per 10,000 population aged 0-17 on the Child Protection Register, March 2014 Rate of children per 10,000 population aged 0-17 on the Child Protection Register, March 2014 Produced by Public Health Wales Observatory, using Children's Services Data (StatsWales) & MYE (ONS) Wales=50 Betsi Cadwaladr Powys Hywel Dda ABM Cardiff & Vale Cwm Taf Aneurin Bevan Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Source: Produced by Public Health Wales Observatory, using Children s Services data (WG) and MYE (ONS) Looked After Children Children become looked after by a Local Authority following a care order granted by the court or through section 20 where the Local Authority accommodates children on a voluntary basis. Since the introduction of the Legal Aid, Sentencing and Punishment of Offenders Act (2012) Young Person s remanded into the care of the Local Authority are subject to Looked After Children regulations. Looked after children are recognised as a vulnerable group, who experience relatively poor life chances and higher morbidity (Welsh Assembly Government 2005). Towards a Stable Life and Brighter Future: Regulations and Guidance (Welsh Government, 2007) provides regulations and guidance to strengthen arrangements for the placement, health, education and wellbeing of looked after children and young people outside of their usual county of residence. These arrangements are intended to ensure that decisions are made in the best interests of the child and that children are placed as close to home as possible. In addition, they are intended to improve co-ordination between agencies, ensuring all agencies co-operate fully in the delivery of their corporate parenting responsibilities. This includes the responsibilities of the Health Board in relation to children who are looked after by Powys County Council. Page 82 of 106

83 Recent research (Cordis Bright Ltd 2013) has highlighted that the main intervention areas that can help reduce the number of looked after children are: Strategy and leadership: a local strategy is in place to reduce the numbers of looked after children and the strategy has buy in from partners Prevention and early intervention: stakeholders work together to provide support and intervention to children and families Approach to practice: there is a clearly defined approach to social work practice Partnership working: there is effective collaborative working focused on improving outcomes for children Information and intelligence about performance: there is high quality information and intelligence providing insight into how effective the system is at protecting and supporting vulnerable children In Powys, the specialist nurses for looked after children (part of the Safeguarding Team), work in line with statutory guidance to co-ordinate the health care plans and address the health care needs of looked after children, care leavers and vulnerable children living away from home. For many young people in care, the specialist nurses are the most consistent health professional that they are involved with as they progress through placements and education. Over the past four years, the number of Powys children in care has, in overall terms, reduced (figure 52). Figure 52: Looked After Children population comparison over 4 years (Quarter 4) in Powys Q4 (10/11) Q4 (11/12) Q4 (12/13) Q4 (13/14) Powys Looked After Children living in Powys Powys Looked After Children living out of Powys Children from Other Local Authorities Source: Powys teaching Health Board This is mainly due to a reduction in the number of Powys looked after children who remain in county, although the number living out of county has remained static. Powys County Council has continued to invest in the Early Intervention and Prevention programme, which underpins all its transformational and strengthening activity. During 2013/14, there continued Page 83 of 106

84 to be a reduction in those children becoming looked after and those children who being placed on the child protection register. In addition, re-referral rates had reduced and there was clear evidence of improved outcomes for these children, young people and their families The number of looked after children from other Local Authorities placed in Powys has increased between 2010/11 and 2013/14. In part, the increase can be linked to new shortterm residential assessment units. The majority of these placements are for children and young people who have complex health and social needs. There are also a number of children from other Local Authorities living in independent foster care placements in Powys. The Powys teaching Health Board Safeguarding team have reported that there is evidence of good multi-agency working demonstrated, for example, through the implementation of the self harm pathway. Page 84 of 106

85 8 Listening to Children The United Nations Convention on the Rights of the Child (UNCRC) declares that children and young people have a right to participate in the decision making processes that are relevant to their lives; and a right to influence the decisions made in their regard within the family, the school or the community. In particular to be provided the opportunity to be heard in any judicial and administrative proceedings affecting the child, either directly, or through an advocate. In Powys, the Children and Young People s Partnership Participation Strategy ( ) has been developed with the aim of ensuring that the children and young people of Powys have the opportunity to contribute and to have their voices heard and their views taken into account in decision making on all issues that affect their lives. Through the strategy, young people are: Helped to reach their full potential Valued. Services will respect young people and promote their health, wellbeing, learning and development Able to access the services they need The Voice of Children and Young People in Powys Young Person s Survey Every year, Powys County Council seeks the views of a representative sample of residents to gauge satisfaction with key services. In 2013, nearly 300 young people aged 11 to 25 years participated in an online survey. The young people were asked to describe living in Powys in a single word. Figure 53 is a word cloud showing the words most commonly used - the size of the word reflects how frequently the word was used by the respondents _14_en.pdf Page 85 of 106

86 Figure 53: Responses by young people when asked to describe living in Powys in a single word Source: CR Market Research 2013 Young people were also asked about their views on key broad themes such as education and transport. Figure 54 shows the responses provided by young people, with themes rates on a scale of 1 to 5, with 1 being very poor and 5 being excellent. Areas which were most frequently rates as excellent in Powys were education, sports and recreation and being a safe place to live. Being able to access a mobile phone signal and internet and housing for young people wanting to live independently were most likely to be rated as very poor. Page 86 of 106

87 Figure 54: Views of young people in Powys, rating key themes from 1 to 5 Source: CR Market Research 2013 Services that young people were most satisfied with were Young Farmers, leisure and sports centres and youth clubs. Young people reported that the services they were most dissatisfied with were public toilets, pothole and road repairs, buses, street lighting and leisure activities such as cinema and festivals. The Role of Professionals There are various ways in which professionals in Powys listen to the children and young people they work with: Powys County Council Youth Services use Facebook as a forum for young people to comment and feedback about services and developments. A survey conducted at Have Your Say Day showed that Facebook was viewed by young people as the best tool Young people from Powys Young Carers have attended a mental health meeting to examine shaping services for young people Page 87 of 106

88 Child and Adolescent Mental Health Service workers have attended a Youth Forum residential to discuss the difficulties young people experience when asking for help with mental health issues Tros Gynnal Plant is a Welsh children s charity working with vulnerable children and young people who may be experiencing difficulties in accessing appropriate health, education or social care services. In Powys, Tros Gynnal Plant run the Powys Advocacy for Children and Young People, an independent advocacy service jointly commissioned by Powys County Council social services and education and Powys teaching Health Board. Powys Advocacy for Children and Young People has launched The Sparks Project, a participation project working with primary school children to gather their views and opinions about the issues that affect them School nurses are creating a questionnaire that can be used in high schools to explore the types of service children and young people feel they want and need. This initiative was as a result of feedback from the Powys Youth Forum, where it was reported that it was difficult to find information about the school nursing service. School nurses are now finalising a leaflet and webpage for school websites to address this and other access issues School nurses carried out a NHS Experience Questionnaire with 40 students after school vaccination sessions. Responses from the questionnaire showed that pupils felt comforted and respected by the nurses that dealt with them. Young people reported that the information provided by school nurses was useful, helping to ensure that they were providing informed consent. By helping pupils to have a positive experience during vaccination, rather than feeling stress and anxiety, school nurses were able to increase the likelihood that pupils were more willing to accept vaccination, not just for themselves but for their children when they become parents A Powys School Nurse speaking about her role: School nurses help improve health outcomes for children and young people. This can be on an individual and group basis and is a key area of the school nurses work. This might range from a short lesson with four year olds about hand washing or a session on testicular cancer awareness with a group of 15 year old boys or an individual appointment with the pupil to discuss healthy lifestyle choices. Young people asked school nurses to hold a workshop during a Have your say consultation event. Following feedback from young people, a workshop was held, focusing on the themes of healthy eating, drug misuse, smoking, sexual health and alcohol use. The workshop was attended by 38 young people aged between 13 and 18 years. Nurses provided advice and support to attendees and led two interactive sessions. Key learning from the workshop included the need for school nurses to Page 88 of 106

89 provide young people with more support and information about alcohol and healthy eating Funky Dragon is a Welsh Government funded youth forum, which has facilitated and promoted children s rights, including the right to be heard. Powys Youth Forum has had representation on the Funky Dragon Grand Council and have actively engaged with its work on a national level. However, in 2014, following a review of third sector grant funding structures, Funky Dragon was unsuccessful in its bid for funding as part of the Children and Families Delivery Grant Recommendation 7 As part of the wider engagement work being led by the Powys Children and Young People s Partnership, Powys teaching Health Board should ensure that its refreshed engagement strategy fully encompasses children and young people Recommendation 8 Leading on from this, Powys teaching Health Board should receive an annual report on all its engagement activities with children and young people in Powys Page 89 of 106

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95 Appendix 1: NICE Public Health Guidance Implementation in Powys NICE Guidance Guidance Summary Implementation in Powys PH24 Alcohol-use Disorders: Preventing Harmful Drinking (2010) PH 7 Interventions in Schools to Prevent and reduce alcohol Use Among Children and Young People (2007) NHS professionals in a range of healthcare services, such as antenatal clinics should offer structured brief advice on alcohol, based on a recognised, evidence based resource. Effective interventions in schools to prevent and reduce alcohol misuse among children and young people should include using: a whole school approach to alcohol which involves staff, parents and pupils, which covers a range of areas including policy development, the school environment and the professional development of (and support for) staff. Alcohol Brief Intervention Training has been delivered to a range of professionals in Powys, including midwives and health visitors. Powys Healthy Schools Team delivers a whole school approach which includes policy development, the school environment and the professional development of and support for staff. PH53 Managing overweight and obesity in adults lifestyle weight management services (2014) Recommendations are made on the provision of effective multi-component lifestyle weight management services for adults (aged 18 and over) who are overweight or obese. It covers weight management programmes, courses, clubs or groups that aim to change behaviour to reduce energy intake and encourage physical active. This guidance is being utilised to ensure that development of the Healthy Weight Strategy and Action Plan compliant with NICE guidance PH47 Managing overweight and obesity among children and young people: lifestyle weight management services (2013) PH27 Weight management, before, during and after pregnancy (2010) Recommendations are made on lifestyle weight management (Tier 2) services for overweight and obese children and young people aged under 18. These services are just one part of a comprehensive approach to preventing and treating obesity. This guidance is for NHS and other commissioners, managers and professionals who have direct or an indirect role in and responsibility for women who are pregnant or who are planning a pregnancy and mothers Page 95 of 106 This guidance was used to inform the development of the childhood obesity action plan. This guidance has informed the development of the research proposal on weight management in pregnancy and is considered within the healthy weight action plan.

96 PH11 Maternal and child health nutrition (2008) PH40 Social and Emotional wellbeing: early years (2012) CG158 Antisocial behaviour and conduct disorders in children and young people: recognition, intervention and management (2013) CG45 Antenatal and postnatal mental health (2007) who have given birth in the last two years. This guidance is for health professionals, commissioners and managers, pharmacists, those providing pre-school childcare and other relevant public, community, voluntary and private sector organisations. It relates to pregnant women (and those who are planning to become pregnant), mothers and other carers of children aged under 5 and their children. The social and emotional wellbeing of vulnerable children aged under 5 years is supported through home visiting, childcare and early education, particularly re ante and post-natal visits for vulnerable children and their families. This guidance makes recommendations in the assessment of children and young people with possible conduct disorder and management approached including parent training programmes, foster carer / guardian training, child focussed programmes, multi-modal interventions and access to services. The advice in the guidance covers recognising mental health problems during and after pregnancy, care and treatment for women with mental health problems and support available to pregnant women. This guidance has related actions within the Powys Healthy Weight Action Plan, including healthy start vitamins, work around the accreditation to the baby friendly initiative and promotion of the baby welcome scheme. This approach has been integrated into the work of the Children and Young Peoples Partnership, Flying Start; Team Around the Family and the Integrated Family Support Service approach. Recommendations have been addressed through the Children and Young Peoples Partnership, for example through Incredible Years parenting programmes, Flying Start and Team Around the Family approach. At both the antenatal booking visit and the post-natal first visit, health professionals ask questions to identify possible depression. PH 14 Preventing the uptake of smoking by children and young people (2008) The guidance includes interventions such as the development of regional campaigns to prevent the uptake of smoking, test purchasing to tackle underage tobacco sales. The recommendations from the guidance have been included in the Powys Tobacco Control Strategy and Action Plan. Page 96 of 106

97 PH26 Quitting smoking in pregnancy and following childbirth (2010) The guidance includes a recommendation that all pregnant women who smoke, all those who are planning a pregnancy or who have an infant aged under 12 months should be referred for help to quit smoking. A referral pathway for pregnant women who smoke has been developed. All midwives have been undergone smoking Brief Intervention Training and have access to carbon monoxide monitors. PH23 School-based interventions to prevent smoking (2010) All those responsible for preventing the uptake of smoking by children and young people aged under 19 (including those working in the NHS, local authorities, education and the wider public, private, voluntary and community sectors) should support prevention and stop smoking activities through policy development, incorporating information on smoking into the classroom and promotion of anti-smoking activities. Substance misuse (including tobacco) is a key phase of the Healthy Schools Scheme. Page 97 of 106

98 Appendix 2: Indicators from Health of Children and Young People in Wales, Public Health Wales Observatory (2013) This section includes data comparing the Powys position with that of Wales for a number of key indicators. It is important to note that the main text of the report may contain more recent data than that contained in this appendix. Key data from 2011 Census Population and births Page 98 of 106

99 Behaviour and immunisations Health and use of services Deaths Page 99 of 106